- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,454.71 / $3,801.89
| Professional | | $2,041.74 | $2,454.71 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $2,290.87 / $3,981.07
| Professional | | $1,584.89 | $2,290.87 | $3,981.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14,454.40 / $14,454.40 / $14,454.40
| Facility | | $14,454.40 | $14,454.40 | $14,454.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15,135.61 / $22,908.68 / $22,908.68
| Professional | | $15,135.61 | $22,908.68 | $22,908.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,819.70 / $3,019.95
| Professional | | $1,288.25 | $1,819.70 | $3,019.95 |