- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,041.74 / $2,041.74
| Professional | | $1,905.46 | $2,041.74 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $154.88 / $245.47 / $245.47
| Professional | | $154.88 | $245.47 | $245.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,398.83 / $2,398.83
| Facility | | $2,398.83 | $2,398.83 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,398.83 / $2,398.83
| Professional | | $2,041.74 | $2,398.83 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $199.53 / $199.53 / $1,778.28
| Facility | | $199.53 | $199.53 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,348.96 / $2,238.72
| Professional | | $1,000.00 | $1,348.96 | $2,238.72 |