- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,839.72 / $3,721.31 / $3,851.12
| Professional | | $2,839.72 | $3,721.31 | $3,851.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,163.37 / $3,438.45 / $3,438.45
| Professional | | $3,163.37 | $3,438.45 | $3,438.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,248.38 / $3,248.38 / $5,117.10
| Facility | | $3,248.38 | $3,248.38 | $5,117.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $415.13 / $3,248.38 / $6,123.75
| Professional | | $415.13 | $3,248.38 | $6,123.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,730.84 / $2,788.43 / $4,110.75
| Professional | | $1,730.84 | $2,788.43 | $4,110.75 |