- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,041.74 / $3,630.78
| Professional | | $1,995.26 | $2,041.74 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,981.07 / $3,981.07 / $3,981.07
| Professional | | $3,981.07 | $3,981.07 | $3,981.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,398.83 / $4,168.69
| Facility | | $2,398.83 | $2,398.83 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,398.83 / $2,398.83
| Professional | | $2,398.83 | $2,398.83 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $151.36 / $1,513.56 / $3,162.28
| Facility | | $151.36 | $1,513.56 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,041.74 / $3,235.94
| Professional | | $1,737.80 | $2,041.74 | $3,235.94 |