- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,615.92 / $2,856.73 / $6,880.87
| Professional | | $2,615.92 | $2,856.73 | $6,880.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,755.35 / $3,059.32 / $3,950.00
| Professional | | $2,755.35 | $3,059.32 | $3,950.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,087.40 / $2,725.07 / $5,857.94
| Professional | | $2,087.40 | $2,725.07 | $5,857.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,381.56 / $3,072.21 / $5,091.63
| Professional | | $2,381.56 | $3,072.21 | $5,091.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $661.00 / $661.00 / $661.00
| Facility | | $661.00 | $661.00 | $661.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,936.46 / $2,608.51 / $5,600.50
| Professional | | $1,936.46 | $2,608.51 | $5,600.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,003.50 / $2,003.50 / $3,339.44
| Professional | | $2,003.50 | $2,003.50 | $3,339.44 |