- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,036.82 / $3,982.23 / $4,537.89
| Professional | | $3,036.82 | $3,982.23 | $4,537.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,948.78 / $3,205.20 / $3,205.20
| Professional | | $2,948.78 | $3,205.20 | $3,205.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,621.85 / $3,621.85 / $3,646.95
| Facility | | $3,621.85 | $3,621.85 | $3,646.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $386.96 / $3,621.85 / $5,707.50
| Professional | | $386.96 | $3,621.85 | $5,707.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,494.94 / $1,993.26 / $3,087.00
| Professional | | $1,494.94 | $1,993.26 | $3,087.00 |