- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,319.51 / $1,319.51 / $2,335.61
| Professional | | $1,319.51 | $1,319.51 | $2,335.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,562.14 / $2,562.14 / $2,562.14
| Professional | | $2,562.14 | $2,562.14 | $2,562.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,217.64 / $2,217.64 / $3,023.21
| Facility | | $2,217.64 | $2,217.64 | $3,023.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,217.64 / $2,217.64 / $2,217.64
| Professional | | $2,217.64 | $2,217.64 | $2,217.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,027.08 / $1,213.82 / $1,825.47
| Professional | | $1,027.08 | $1,213.82 | $1,825.47 |