- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,369.79 / $3,913.83 / $4,144.05
| Professional | | $2,369.79 | $3,913.83 | $4,144.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,807.80 / $3,807.80 / $3,807.80
| Professional | | $3,807.80 | $3,807.80 | $3,807.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,349.85 / $3,349.85 / $3,349.85
| Facility | | $3,349.85 | $3,349.85 | $3,349.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $356.67 / $3,349.85 / $5,261.25
| Professional | | $356.67 | $3,349.85 | $5,261.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,160.88 / $1,741.32 / $3,463.16
| Professional | | $1,160.88 | $1,741.32 | $3,463.16 |