- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,333.95 / $2,218.48 / $3,330.19
| Professional | | $1,333.95 | $2,218.48 | $3,330.19 |
- 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
- $2,183.76 / $2,183.76 / $6,060.94
| Professional | | $2,183.76 | $2,183.76 | $6,060.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,675.04 / $2,675.04 / $2,675.04
| Professional | | $2,675.04 | $2,675.04 | $2,675.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.36 / $200.63 / $402.16
| Professional | | $177.36 | $200.63 | $402.16 |