- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,454.71 / $2,754.23
| Professional | | $1,949.84 | $2,454.71 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,630.78 / $4,570.88 / $9,332.54
| Professional | | $3,630.78 | $4,570.88 | $9,332.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,888.44 / $5,888.44 / $5,888.44
| Facility | | $5,888.44 | $5,888.44 | $5,888.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $2,884.03 / $2,884.03
| Facility | | $2,884.03 | $2,884.03 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,230.27 / $2,884.03
| Professional | | $1,230.27 | $1,230.27 | $2,884.03 |