- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,818.38 / $2,884.03 / $5,011.87
| Professional | | $2,818.38 | $2,884.03 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,623.41 / $5,623.41 / $5,623.41
| Professional | | $5,623.41 | $5,623.41 | $5,623.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.31 / $3,311.31 / $5,754.40
| Facility | | $3,311.31 | $3,311.31 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,311.31 / $3,311.31 / $3,311.31
| Professional | | $3,311.31 | $3,311.31 | $3,311.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $218.78 / $2,187.76 / $4,466.84
| Facility | | $218.78 | $2,187.76 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,884.03 / $4,570.88
| Professional | | $2,454.71 | $2,884.03 | $4,570.88 |