- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,148.15 / $2,041.74
| Professional | | $1,122.02 | $1,148.15 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,238.72 / $2,238.72
| Professional | | $2,238.72 | $2,238.72 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,071.52 / $1,949.84
| Facility | | $1,071.52 | $1,071.52 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,071.52 / $1,071.52
| Professional | | $1,071.52 | $1,071.52 | $1,071.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $74.13 / $741.31 / $1,548.82
| Facility | | $74.13 | $741.31 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $977.24 / $1,548.82
| Professional | | $831.76 | $977.24 | $1,548.82 |