- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,830.17 / $3,007.90 / $3,184.83
| Professional | | $1,830.17 | $3,007.90 | $3,184.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,742.80 / $2,742.80 / $2,742.80
| Professional | | $2,742.80 | $2,742.80 | $2,742.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,254.90 / $2,254.90 / $3,052.83
| Facility | | $2,254.90 | $2,254.90 | $3,052.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $267.70 / $2,254.90 / $3,993.75
| Professional | | $267.70 | $2,254.90 | $3,993.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $857.20 / $1,338.40 / $2,798.29
| Professional | | $857.20 | $1,338.40 | $2,798.29 |