- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $2,290.87 / $2,630.27
| Professional | | $1,659.59 | $2,290.87 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $2,630.27 / $3,630.78
| Professional | | $2,570.40 | $2,630.27 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $3,019.95 / $5,754.40
| Facility | | $2,041.74 | $3,019.95 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,288.25 / $15,135.61
| Professional | | $1,288.25 | $1,288.25 | $15,135.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,288.25 / $1,819.70
| Professional | | $1,288.25 | $1,288.25 | $1,819.70 |