- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,659.59 / $1,905.46
| Professional | | $1,202.26 | $1,659.59 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,187.76 / $3,019.95
| Professional | | $2,137.96 | $2,187.76 | $3,019.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,479.11 / $2,238.72 / $4,073.80
| Facility | | $1,479.11 | $2,238.72 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $933.25 / $10,964.78
| Professional | | $933.25 | $933.25 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $933.25 / $1,318.26
| Professional | | $933.25 | $933.25 | $1,318.26 |