- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $3,388.44 / $5,754.40
| Professional | | $2,570.40 | $3,388.44 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,570.88 / $4,570.88 / $4,570.88
| Professional | | $4,570.88 | $4,570.88 | $4,570.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,073.80 / $4,073.80 / $10,232.93
| Facility | | $4,073.80 | $4,073.80 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,951.21 / $2,951.21 / $7,244.36
| Professional | | $2,951.21 | $2,951.21 | $7,244.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $4,168.69 / $7,585.78
| Facility | | $3,715.35 | $4,168.69 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,818.38 / $4,265.80
| Professional | | $1,862.09 | $2,818.38 | $4,265.80 |