- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,680.63 / $2,213.73 / $2,290.94
| Professional | | $1,680.63 | $2,213.73 | $2,290.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,854.08 / $2,015.30 / $2,015.30
| Professional | | $1,854.08 | $2,015.30 | $2,015.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,406.76 / $1,406.76 / $3,020.16
| Facility | | $1,406.76 | $1,406.76 | $3,020.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.80 / $1,406.76 / $3,588.75
| Professional | | $218.80 | $1,406.76 | $3,588.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $868.60 / $1,257.71 / $1,908.76
| Professional | | $868.60 | $1,257.71 | $1,908.76 |