- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,185.49 / $1,570.48 / $2,220.48
| Professional | | $1,185.49 | $1,570.48 | $2,220.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.80 / $1,905.80 / $1,905.80
| Professional | | $1,905.80 | $1,905.80 | $1,905.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $213.28 / $1,414.26 / $1,414.26
| Facility | | $213.28 | $1,414.26 | $1,414.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $199.14 / $1,414.26 / $3,266.25
| Professional | | $199.14 | $1,414.26 | $3,266.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $796.56 / $1,405.68 / $2,433.34
| Professional | | $796.56 | $1,405.68 | $2,433.34 |