- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,354.35 / $1,825.71 / $1,931.88
| Professional | | $1,354.35 | $1,825.71 | $1,931.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,975.09 / $2,323.64 / $3,729.59
| Professional | | $1,975.09 | $2,323.64 | $3,729.59 |
- 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
- $2,271.73 / $2,672.64 / $2,672.64
| Professional | | $2,271.73 | $2,672.64 | $2,672.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,444.64 / $2,100.13 / $3,500.22
| Professional | | $1,444.64 | $2,100.13 | $3,500.22 |