- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,923.87 / $3,941.47 / $4,170.71
| Professional | | $2,923.87 | $3,941.47 | $4,170.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,148.62 / $5,148.62 / $5,148.62
| Professional | | $5,148.62 | $5,148.62 | $5,148.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,969.00 / $3,969.00 / $3,969.00
| Facility | | $3,969.00 | $3,969.00 | $3,969.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,373.65 / $3,373.65 / $3,373.65
| Professional | | $3,373.65 | $3,373.65 | $3,373.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $534.91 / $534.91 / $3,566.08
| Facility | | $534.91 | $534.91 | $3,566.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,079.19 / $3,174.84 / $5,291.40
| Professional | | $2,079.19 | $3,174.84 | $5,291.40 |