- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,060.38 / $4,013.10 / $4,573.07
| Professional | | $3,060.38 | $4,013.10 | $4,573.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,979.02 / $3,238.07 / $3,238.07
| Professional | | $2,979.02 | $3,238.07 | $3,238.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,657.49 / $3,657.49 / $3,675.31
| Facility | | $3,657.49 | $3,657.49 | $3,675.31 |
- 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 / $2,177.65 / $3,110.93
| Professional | | $1,244.36 | $2,177.65 | $3,110.93 |