- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,858.91 / $3,069.62 / $3,250.19
| Professional | | $1,858.91 | $3,069.62 | $3,250.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,990.52 / $2,990.52 / $2,990.52
| Professional | | $2,990.52 | $2,990.52 | $2,990.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,672.64 / $2,672.64 / $2,672.64
| Facility | | $2,672.64 | $2,672.64 | $2,672.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,672.64 / $2,672.64 / $4,729.50
| Professional | | $2,672.64 | $2,672.64 | $4,729.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,300.18 / $2,047.28 / $3,120.86
| Professional | | $1,300.18 | $2,047.28 | $3,120.86 |