- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,285.82 / $3,188.97 / $3,300.21
| Professional | | $2,285.82 | $3,188.97 | $3,300.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,670.94 / $2,903.20 / $2,903.20
| Professional | | $2,670.94 | $2,903.20 | $2,903.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,225.05 / $2,225.05 / $2,225.05
| Facility | | $2,225.05 | $2,225.05 | $2,225.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $343.68 / $2,225.05 / $5,261.25
| Professional | | $343.68 | $2,225.05 | $5,261.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $988.83 / $1,491.36 / $2,472.07
| Professional | | $988.83 | $1,491.36 | $2,472.07 |