- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,454.71 / $3,162.28
| Professional | | $1,698.24 | $2,454.71 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $2,754.23 / $2,754.23
| Professional | | $2,754.23 | $2,754.23 | $2,754.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,238.72 / $3,019.95
| Facility | | $2,238.72 | $2,238.72 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $269.15 / $2,238.72 / $3,981.07
| Professional | | $269.15 | $2,238.72 | $3,981.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $169.82 / $346.74 / $2,187.76
| Facility | | $169.82 | $346.74 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,548.82 / $2,754.23
| Professional | | $891.25 | $1,548.82 | $2,754.23 |