- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $3,467.37 / $4,168.69
| Professional | | $2,137.96 | $3,467.37 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,235.94 / $3,235.94 / $3,235.94
| Professional | | $3,235.94 | $3,235.94 | $3,235.94 |
- 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
- $223.87 / $436.52 / $2,754.23
| Facility | | $223.87 | $436.52 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $2,041.74 / $3,388.44
| Professional | | $1,479.11 | $2,041.74 | $3,388.44 |