- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,796.05 / $2,421.14 / $2,561.85
| Professional | | $1,796.05 | $2,421.14 | $2,561.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,619.23 / $3,081.46 / $3,081.46
| Professional | | $2,619.23 | $3,081.46 | $3,081.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,282.89 / $3,282.89 / $3,282.89
| Facility | | $3,282.89 | $3,282.89 | $3,282.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,790.46 / $3,282.89 / $3,282.89
| Professional | | $2,790.46 | $3,282.89 | $3,282.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,222.73 / $2,859.96 / $4,896.10
| Professional | | $2,222.73 | $2,859.96 | $4,896.10 |