- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,732.58 / $3,196.17 / $3,232.08
| Professional | | $1,732.58 | $3,196.17 | $3,232.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,787.29 / $2,787.29 / $2,787.29
| Professional | | $2,787.29 | $2,787.29 | $2,787.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,399.94 / $2,399.94 / $2,399.94
| Facility | | $2,399.94 | $2,399.94 | $2,399.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $326.16 / $2,399.94 / $4,777.50
| Professional | | $326.16 | $2,399.94 | $4,777.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,357.08 / $2,035.62 / $3,223.07
| Professional | | $1,357.08 | $2,035.62 | $3,223.07 |