- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,697.31 / $2,289.84 / $2,830.96
| Professional | | $1,697.31 | $2,289.84 | $2,830.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,717.60 / $3,739.12 / $3,739.12
| Professional | | $3,717.60 | $3,739.12 | $3,739.12 |
- 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
- $1,916.67 / $1,916.67 / $2,254.90
| Professional | | $1,916.67 | $1,916.67 | $2,254.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,285.80 / $1,608.92 / $2,633.68
| Professional | | $1,285.80 | $1,608.92 | $2,633.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,655.12 / $3,863.61 / $3,863.61
| Professional | | $2,655.12 | $3,863.61 | $3,863.61 |