- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,827.87 / $2,464.04 / $2,607.28
| Professional | | $1,827.87 | $2,464.04 | $2,607.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,665.65 / $3,136.06 / $3,136.06
| Professional | | $2,665.65 | $3,136.06 | $3,136.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,642.21 / $1,642.21 / $1,642.21
| Facility | | $1,642.21 | $1,642.21 | $1,642.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,395.88 / $1,642.21 / $1,642.21
| Professional | | $1,395.88 | $1,642.21 | $1,642.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,262.12 / $2,938.92 / $5,012.10
| Professional | | $2,262.12 | $2,938.92 | $5,012.10 |