- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,419.06 / $1,869.12 / $1,934.33
| Professional | | $1,419.06 | $1,869.12 | $1,934.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,565.52 / $1,701.65 / $1,701.65
| Professional | | $1,565.52 | $1,701.65 | $1,701.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,450.41 / $1,450.41 / $2,550.10
| Facility | | $1,450.41 | $1,450.41 | $2,550.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $184.74 / $1,232.84 / $3,787.50
| Professional | | $184.74 | $1,232.84 | $3,787.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $733.34 / $1,019.93 / $1,611.52
| Professional | | $733.34 | $1,019.93 | $1,611.52 |