- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,136.26 / $2,136.26 / $2,136.26
| Professional | | $2,136.26 | $2,136.26 | $2,136.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,061.40 / $3,061.40 / $3,667.90
| Professional | | $3,061.40 | $3,061.40 | $3,667.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,859.81 / $2,450.42 / $5,296.50
| Facility | | $1,859.81 | $2,450.42 | $5,296.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,055.57 / $1,055.57 / $13,612.50
| Professional | | $1,055.57 | $1,055.57 | $13,612.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,055.57 / $1,055.57 / $2,513.25
| Professional | | $1,055.57 | $1,055.57 | $2,513.25 |