- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,918.65 / $2,515.67 / $2,689.49
| Professional | | $1,918.65 | $2,515.67 | $2,689.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,939.76 / $3,195.39 / $3,195.39
| Professional | | $2,939.76 | $3,195.39 | $3,195.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,304.34 / $2,387.48 / $2,387.48
| Facility | | $2,304.34 | $2,387.48 | $2,387.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.77 / $2,387.48 / $3,993.75
| Professional | | $251.77 | $2,387.48 | $3,993.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.06 / $1,333.17 / $1,950.13
| Professional | | $891.06 | $1,333.17 | $1,950.13 |