- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,958.83 / $3,473.75 / $3,577.44
| Professional | | $2,958.83 | $3,473.75 | $3,577.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,629.29 / $3,629.29 / $4,393.09
| Professional | | $3,629.29 | $3,629.29 | $4,393.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,642.21 / $1,642.21 / $1,642.21
| Facility | | $1,642.21 | $1,642.21 | $1,642.21 |
- 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
- $596.75 / $596.75 / $596.75
| Professional | | $596.75 | $596.75 | $596.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,324.44 / $2,938.92 / $3,877.32
| Professional | | $2,324.44 | $2,938.92 | $3,877.32 |