- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $3,162.28 / $3,715.35
| Professional | | $1,995.26 | $3,162.28 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,818.38 / $2,818.38 / $2,818.38
| Professional | | $2,818.38 | $2,818.38 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,691.53 / $2,691.53 / $3,388.44
| Facility | | $2,691.53 | $2,691.53 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $2,691.53 / $5,128.61
| Professional | | $346.74 | $2,691.53 | $5,128.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $204.17 / $398.11 / $2,570.40
| Facility | | $204.17 | $398.11 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,862.09 / $3,019.95
| Professional | | $1,412.54 | $1,862.09 | $3,019.95 |