- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,759.77 / $3,113.04 / $3,296.16
| Professional | | $1,759.77 | $3,113.04 | $3,296.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,215.40 / $3,215.40 / $3,215.40
| Professional | | $3,215.40 | $3,215.40 | $3,215.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,569.13 / $2,569.13 / $2,569.13
| Facility | | $2,569.13 | $2,569.13 | $2,569.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $295.60 / $2,569.13 / $6,060.94
| Professional | | $295.60 | $2,569.13 | $6,060.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $118.24 / $208.66 / $1,687.74
| Professional | | $118.24 | $208.66 | $1,687.74 |