- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,381.32 / $3,210.11 / $3,396.69
| Professional | | $2,381.32 | $3,210.11 | $3,396.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,472.76 / $4,085.60 / $4,085.60
| Professional | | $3,472.76 | $4,085.60 | $4,085.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,775.22 / $4,775.22 / $4,775.22
| Facility | | $4,775.22 | $4,775.22 | $4,775.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,058.94 / $4,775.22 / $4,775.22
| Professional | | $4,058.94 | $4,775.22 | $4,775.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,947.05 / $4,434.06 / $8,001.50
| Professional | | $2,947.05 | $4,434.06 | $8,001.50 |