- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,214.51 / $4,212.45 / $4,359.39
| Professional | | $3,214.51 | $4,212.45 | $4,359.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,573.94 / $3,884.72 / $3,884.72
| Professional | | $3,573.94 | $3,884.72 | $3,884.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,642.21 / $1,642.21 / $5,792.58
| Facility | | $1,642.21 | $1,642.21 | $5,792.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $470.42 / $1,642.21 / $6,918.75
| Professional | | $470.42 | $1,642.21 | $6,918.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,959.28 / $3,156.45 / $4,652.78
| Professional | | $1,959.28 | $3,156.45 | $4,652.78 |