- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,540.10 / $2,661.73 / $2,984.17
| Professional | | $2,540.10 | $2,661.73 | $2,984.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,122.10 / $2,583.84 / $2,583.84
| Professional | | $2,122.10 | $2,583.84 | $2,583.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,416.31 / $2,416.31 / $2,416.31
| Facility | | $2,416.31 | $2,416.31 | $2,416.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,053.86 / $2,416.31 / $2,416.31
| Professional | | $2,053.86 | $2,416.31 | $2,416.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,178.20 / $1,426.56 / $2,186.01
| Professional | | $1,178.20 | $1,426.56 | $2,186.01 |