- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,238.72 / $2,818.38
| Professional | | $1,778.28 | $2,238.72 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,388.44 / $3,388.44 / $3,388.44
| Professional | | $3,388.44 | $3,388.44 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $2,570.40 / $2,691.53
| Facility | | $2,570.40 | $2,570.40 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $295.12 / $2,187.76 / $2,570.40
| Professional | | $295.12 | $2,187.76 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $141.25 / $331.13 / $1,949.84
| Facility | | $141.25 | $331.13 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,659.59 / $2,818.38
| Professional | | $1,288.25 | $1,659.59 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $3,801.89 / $3,801.89
| Professional | | $2,691.53 | $3,801.89 | $3,801.89 |