- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,708.66 / $2,303.35 / $2,437.27
| Professional | | $1,708.66 | $2,303.35 | $2,437.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $249.18 / $293.14 / $293.14
| Professional | | $249.18 | $293.14 | $293.14 |
- 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
- $1,186.57 / $1,737.24 / $2,519.07
| Professional | | $1,186.57 | $1,737.24 | $2,519.07 |