- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,737.80 / $2,089.30
| Professional | | $1,479.11 | $1,737.80 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,311.31 / $5,011.87 / $5,011.87
| Professional | | $3,311.31 | $5,011.87 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $2,570.40 / $3,162.28
| Professional | | $2,570.40 | $2,570.40 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,584.89 / $2,089.30
| Facility | | $1,318.26 | $1,584.89 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $3,235.94 / $10,964.78
| Professional | | $2,754.23 | $3,235.94 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $2,754.23 / $3,388.44
| Professional | | $933.25 | $2,754.23 | $3,388.44 |