- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,479.11 / $3,890.45
| Professional | | $1,445.44 | $1,479.11 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,090.30 / $3,890.45 / $4,677.35
| Professional | | $3,090.30 | $3,890.45 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,630.27 / $3,467.37
| Professional | | $1,905.46 | $2,630.27 | $3,467.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,288.25 / $3,090.30
| Facility | | $1,288.25 | $1,288.25 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $3,090.30 / $5,011.87
| Professional | | $1,621.81 | $3,090.30 | $5,011.87 |