- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,833.86 / $2,391.12 / $3,002.96
| Professional | | $1,833.86 | $2,391.12 | $3,002.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,599.10 / $3,599.10 / $3,599.10
| Professional | | $3,599.10 | $3,599.10 | $3,599.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,671.66 / $2,671.66 / $2,671.66
| Facility | | $2,671.66 | $2,671.66 | $2,671.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $286.64 / $2,270.91 / $2,671.66
| Professional | | $286.64 | $2,270.91 | $2,671.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,361.32 / $1,700.40 / $3,182.30
| Professional | | $1,361.32 | $1,700.40 | $3,182.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,852.72 / $4,034.19 / $4,034.19
| Professional | | $2,852.72 | $4,034.19 | $4,034.19 |