- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,302.50 / $2,304.10 / $2,439.63
| Professional | | $1,302.50 | $2,304.10 | $2,439.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,450.23 / $2,450.23 / $2,450.23
| Professional | | $2,450.23 | $2,450.23 | $2,450.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,406.76 / $1,406.76 / $1,406.76
| Facility | | $1,406.76 | $1,406.76 | $1,406.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.80 / $1,406.76 / $3,588.75
| Professional | | $218.80 | $1,406.76 | $3,588.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $868.60 / $1,249.21 / $2,062.92
| Professional | | $868.60 | $1,249.21 | $2,062.92 |