- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,367.41 / $3,134.05 / $3,204.30
| Professional | | $2,367.41 | $3,134.05 | $3,204.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,733.10 / $2,733.10 / $2,733.10
| Professional | | $2,733.10 | $2,733.10 | $2,733.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,569.13 / $2,569.13 / $2,569.13
| Facility | | $2,569.13 | $2,569.13 | $2,569.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,183.76 / $2,183.76 / $2,183.76
| Professional | | $2,183.76 | $2,183.76 | $2,183.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $136.66 / $200.63 / $376.43
| Professional | | $136.66 | $200.63 | $376.43 |