- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,090.30 / $3,162.28 / $5,495.41
| Professional | | $3,090.30 | $3,162.28 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,165.95 / $6,165.95 / $6,165.95
| Professional | | $6,165.95 | $6,165.95 | $6,165.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,467.37 / $6,309.57
| Facility | | $3,467.37 | $3,467.37 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,467.37 / $3,467.37
| Professional | | $3,467.37 | $3,467.37 | $3,467.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $234.42 / $2,344.23 / $4,897.79
| Facility | | $234.42 | $2,344.23 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,630.27 / $3,162.28 / $4,897.79
| Professional | | $2,630.27 | $3,162.28 | $4,897.79 |