- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,128.09 / $4,099.28 / $4,671.27
| Professional | | $3,128.09 | $4,099.28 | $4,671.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,476.97 / $3,779.32 / $3,779.32
| Professional | | $3,476.97 | $3,779.32 | $3,779.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,282.89 / $3,282.89 / $5,636.78
| Facility | | $3,282.89 | $3,282.89 | $5,636.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $456.28 / $3,282.89 / $6,731.25
| Professional | | $456.28 | $3,282.89 | $6,731.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,906.64 / $2,937.66 / $4,528.27
| Professional | | $1,906.64 | $2,937.66 | $4,528.27 |