- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,872.50 / $3,345.77 / $3,520.57
| Professional | | $2,872.50 | $3,345.77 | $3,520.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,230.86 / $2,230.86 / $2,231.25
| Professional | | $2,230.86 | $2,230.86 | $2,231.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,446.40 / $2,446.40 / $2,446.40
| Facility | | $2,446.40 | $2,446.40 | $2,446.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,079.44 / $2,446.40 / $3,210.83
| Professional | | $2,079.44 | $2,446.40 | $3,210.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,275.05 / $1,700.16 / $2,605.27
| Professional | | $1,275.05 | $1,700.16 | $2,605.27 |