- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,448.08 / $1,897.83 / $2,162.64
| Professional | | $1,448.08 | $1,897.83 | $2,162.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,505.29 / $1,636.19 / $1,636.19
| Professional | | $1,505.29 | $1,636.19 | $1,636.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,204.08 / $2,217.64 / $2,217.64
| Facility | | $2,204.08 | $2,217.64 | $2,217.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,884.99 / $2,217.64 / $3,059.25
| Professional | | $1,884.99 | $2,217.64 | $3,059.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $882.71 / $1,311.11 / $2,096.44
| Professional | | $882.71 | $1,311.11 | $2,096.44 |