- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,193.98 / $2,877.56 / $2,977.94
| Professional | | $2,193.98 | $2,877.56 | $2,977.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,125.78 / $3,397.59 / $3,397.59
| Professional | | $3,125.78 | $3,397.59 | $3,397.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,254.90 / $2,254.90 / $2,254.90
| Facility | | $2,254.90 | $2,254.90 | $2,254.90 |
- 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 / $1,559.88 / $2,230.67
| Professional | | $857.20 | $1,559.88 | $2,230.67 |