- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $3,388.44 / $4,365.16
| Professional | | $2,344.23 | $3,388.44 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,548.13 / $3,548.13 / $3,548.13
| Professional | | $3,548.13 | $3,548.13 | $3,548.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,630.78 / $3,630.78 / $3,715.35
| Facility | | $3,630.78 | $3,630.78 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.05 / $3,630.78 / $5,754.40
| Professional | | $389.05 | $3,630.78 | $5,754.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $213.80 / $501.19 / $2,951.21
| Facility | | $213.80 | $501.19 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,995.26 / $3,548.13
| Professional | | $1,230.27 | $1,995.26 | $3,548.13 |