- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,614.92 / $2,535.89 / $2,685.06
| Professional | | $1,614.92 | $2,535.89 | $2,685.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,964.90 / $1,964.90 / $1,964.90
| Professional | | $1,964.90 | $1,964.90 | $1,964.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,225.09 / $2,225.09 / $2,225.09
| Facility | | $2,225.09 | $2,225.09 | $2,225.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $246.17 / $2,225.09 / $3,768.75
| Professional | | $246.17 | $2,225.09 | $3,768.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $737.71 / $1,127.96 / $1,967.04
| Professional | | $737.71 | $1,127.96 | $1,967.04 |