- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,849.71 / $2,425.11 / $2,531.55
| Professional | | $1,849.71 | $2,425.11 | $2,531.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,874.24 / $3,124.17 / $3,124.17
| Professional | | $2,874.24 | $3,124.17 | $3,124.17 |
- 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
- $751.97 / $1,243.16 / $1,879.93
| Professional | | $751.97 | $1,243.16 | $1,879.93 |