- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,422.75 / $1,517.60 / $1,517.60
| Professional | | $1,422.75 | $1,517.60 | $1,517.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,620.11 / $6,620.11 / $7,931.64
| Professional | | $6,620.11 | $6,620.11 | $7,931.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,354.46 / $1,593.48 / $7,880.75
| Facility | | $1,354.46 | $1,593.48 | $7,880.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $796.74 / $796.74 / $27,066.30
| Professional | | $796.74 | $796.74 | $27,066.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $796.74 / $796.74 / $7,123.67
| Professional | | $796.74 | $796.74 | $7,123.67 |