- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,139.09 / $1,494.68 / $1,494.68
| Professional | | $1,139.09 | $1,494.68 | $1,494.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,074.35 / $2,074.35 / $2,074.35
| Professional | | $2,074.35 | $2,074.35 | $2,074.35 |
- 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 / $1,202.11 / $1,414.26
| Professional | | $199.14 | $1,202.11 | $1,414.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,209.46 / $6,202.20 / $7,861.07
| Professional | | $2,209.46 | $6,202.20 | $7,861.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $901.16 / $1,351.74 / $2,102.19
| Professional | | $901.16 | $1,351.74 | $2,102.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,128.46 / $2,358.29 / $3,001.46
| Professional | | $2,128.46 | $2,358.29 | $3,001.46 |