- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,446.77 / $3,209.69 / $3,657.56
| Professional | | $2,446.77 | $3,209.69 | $3,657.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,350.44 / $3,641.78 / $3,641.78
| Professional | | $3,350.44 | $3,641.78 | $3,641.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,446.40 / $2,446.40 / $2,937.79
| Facility | | $2,446.40 | $2,446.40 | $2,937.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $286.94 / $2,446.40 / $4,372.50
| Professional | | $286.94 | $2,446.40 | $4,372.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $995.25 / $1,782.92 / $2,598.38
| Professional | | $995.25 | $1,782.92 | $2,598.38 |