- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,391.12 / $2,423.12 / $2,495.44
| Professional | | $2,391.12 | $2,423.12 | $2,495.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,405.76 / $2,531.62 / $2,852.72
| Professional | | $2,405.76 | $2,531.62 | $2,852.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,671.66 / $2,671.66 / $2,671.66
| Facility | | $2,671.66 | $2,671.66 | $2,671.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $286.64 / $2,671.66 / $4,515.00
| Professional | | $286.64 | $2,671.66 | $4,515.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $343.56 / $343.56 / $343.56
| Professional | | $343.56 | $343.56 | $343.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $882.48 / $1,361.32 / $2,586.83
| Professional | | $882.48 | $1,361.32 | $2,586.83 |