- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,863.26 / $2,511.73 / $2,657.77
| Professional | | $1,863.26 | $2,511.73 | $2,657.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $271.73 / $319.68 / $319.68
| Professional | | $271.73 | $319.68 | $319.68 |
- 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 / $2,254.90 / $2,254.90
| Professional | | $1,916.67 | $2,254.90 | $2,254.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,287.00 / $1,848.96 / $2,681.53
| Professional | | $1,287.00 | $1,848.96 | $2,681.53 |