- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,818.38 / $3,162.28
| Professional | | $2,290.87 | $2,818.38 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,630.27 / $2,630.27
| Professional | | $2,290.87 | $2,630.27 | $2,630.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,238.72 / $2,238.72
| Facility | | $2,238.72 | $2,238.72 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $295.12 / $1,905.46 / $2,238.72
| Professional | | $295.12 | $1,905.46 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $204.17 / $354.81 / $2,398.83
| Facility | | $204.17 | $354.81 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,479.11 / $2,137.96
| Professional | | $1,288.25 | $1,479.11 | $2,137.96 |