- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,869.97 / $3,380.35 / $3,481.26
| Professional | | $2,869.97 | $3,380.35 | $3,481.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,531.71 / $3,531.71 / $4,316.60
| Professional | | $3,531.71 | $3,531.71 | $4,316.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,282.89 / $3,282.89 / $3,282.89
| Facility | | $3,282.89 | $3,282.89 | $3,282.89 |
- 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
- $586.34 / $586.34 / $586.34
| Professional | | $586.34 | $586.34 | $586.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,955.53 / $2,859.96 / $4,766.60
| Professional | | $1,955.53 | $2,859.96 | $4,766.60 |