- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,772.32 / $1,772.32 / $3,410.00
| Professional | | $1,772.32 | $1,772.32 | $3,410.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,475.87 / $1,631.23 / $2,097.29
| Professional | | $1,475.87 | $1,631.23 | $2,097.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,700.19 / $2,700.19 / $3,375.24
| Professional | | $2,700.19 | $2,700.19 | $3,375.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,867.26 / $3,867.26 / $3,867.26
| Facility | | $3,867.26 | $3,867.26 | $3,867.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,126.78 / $2,126.78 / $3,012.94
| Professional | | $2,126.78 | $2,126.78 | $3,012.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $930.47 / $1,329.24 / $1,883.09
| Professional | | $930.47 | $1,329.24 | $1,883.09 |