- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,099.74 / $1,945.48 / $2,059.92
| Professional | | $1,099.74 | $1,945.48 | $2,059.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,767.76 / $1,767.76 / $1,767.76
| Professional | | $1,767.76 | $1,767.76 | $1,767.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,450.41 / $1,450.41 / $1,450.41
| Facility | | $1,450.41 | $1,450.41 | $1,450.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $184.74 / $1,450.41 / $3,787.50
| Professional | | $184.74 | $1,450.41 | $3,787.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $733.34 / $1,097.81 / $1,498.48
| Professional | | $733.34 | $1,097.81 | $1,498.48 |