- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,905.46 / $2,818.38
| Professional | | $1,621.81 | $1,905.46 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $2,691.53 / $3,235.94
| Professional | | $2,691.53 | $2,691.53 | $3,235.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,737.80 / $3,235.94
| Facility | | $1,621.81 | $1,737.80 | $3,235.94 |
- 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 / $2,238.72
| Professional | | $933.25 | $933.25 | $2,238.72 |