- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,629.41 / $1,629.41 / $1,629.41
| Professional | | $1,629.41 | $1,629.41 | $1,629.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,655.97 / $3,655.97 / $3,655.97
| Facility | | $3,655.97 | $3,655.97 | $3,655.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $408.57 / $3,655.97 / $5,865.00
| Professional | | $408.57 | $3,655.97 | $5,865.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,693.92 / $3,910.53 / $5,669.35
| Professional | | $2,693.92 | $3,910.53 | $5,669.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,486.78 / $1,878.68 / $2,970.41
| Professional | | $1,486.78 | $1,878.68 | $2,970.41 |