- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $2,238.72 / $2,630.27
| Professional | | $1,288.25 | $2,238.72 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,162.28 / $3,162.28
| Professional | | $3,162.28 | $3,162.28 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $2,398.83 / $2,398.83
| Facility | | $2,344.23 | $2,398.83 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.19 / $2,398.83 / $3,981.07
| Professional | | $251.19 | $2,398.83 | $3,981.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $134.90 / $269.15 / $1,621.81
| Facility | | $134.90 | $269.15 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,318.26 / $2,041.74
| Professional | | $891.25 | $1,318.26 | $2,041.74 |