- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $2,137.96 / $2,511.89
| Professional | | $1,659.59 | $2,137.96 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,090.30 / $3,890.45 / $7,943.28
| Professional | | $3,090.30 | $3,890.45 | $7,943.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,011.87 / $5,011.87 / $5,011.87
| Facility | | $5,011.87 | $5,011.87 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,884.03 / $2,884.03 / $3,548.13
| Professional | | $2,884.03 | $2,884.03 | $3,548.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,511.89 / $2,511.89 / $2,511.89
| Facility | | $2,511.89 | $2,511.89 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,047.13 / $2,511.89
| Professional | | $1,047.13 | $1,047.13 | $2,511.89 |