- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,584.89 / $2,041.74
| Professional | | $1,096.48 | $1,584.89 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,041.74 / $2,041.74
| Professional | | $2,041.74 | $2,041.74 | $2,041.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $190.55 / $1,445.44 / $2,570.40
| Facility | | $190.55 | $1,445.44 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.97 / $1,445.44 / $3,019.95
| Professional | | $181.97 | $1,445.44 | $3,019.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $102.33 / $741.31 / $1,445.44
| Facility | | $102.33 | $741.31 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $1,047.13 / $1,737.80
| Professional | | $724.44 | $1,047.13 | $1,737.80 |