- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,597.39 / $4,195.68 / $4,442.49
| Professional | | $2,597.39 | $4,195.68 | $4,442.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,528.60 / $3,528.60 / $3,528.60
| Professional | | $3,528.60 | $3,528.60 | $3,528.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,657.49 / $3,657.49 / $3,657.49
| Facility | | $3,657.49 | $3,657.49 | $3,657.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $390.93 / $3,657.49 / $5,767.50
| Professional | | $390.93 | $3,657.49 | $5,767.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,244.36 / $1,866.56 / $3,682.46
| Professional | | $1,244.36 | $1,866.56 | $3,682.46 |