- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,611.16 / $3,068.73 / $3,160.34
| Professional | | $2,611.16 | $3,068.73 | $3,160.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,206.14 / $3,206.14 / $3,893.06
| Professional | | $3,206.14 | $3,206.14 | $3,893.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,248.38 / $3,248.38 / $3,248.38
| Facility | | $3,248.38 | $3,248.38 | $3,248.38 |
- 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
- $528.83 / $528.83 / $528.83
| Professional | | $528.83 | $528.83 | $528.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,051.19 / $2,596.26 / $4,327.10
| Professional | | $2,051.19 | $2,596.26 | $4,327.10 |