- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $1,905.46 / $4,570.88
| Professional | | $1,698.24 | $1,905.46 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,090.30 / $3,090.30 / $3,630.78
| Professional | | $3,090.30 | $3,090.30 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,344.23 / $5,248.07
| Facility | | $1,862.09 | $2,344.23 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,047.13 / $13,489.63
| Professional | | $1,047.13 | $1,047.13 | $13,489.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,047.13 / $2,511.89
| Professional | | $1,047.13 | $1,047.13 | $2,511.89 |