- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,063.22 / $5,063.22 / $5,063.22
| Professional | | $5,063.22 | $5,063.22 | $5,063.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,810.43 / $1,970.06 / $2,327.65
| Professional | | $1,810.43 | $1,970.06 | $2,327.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,249.90 / $1,853.85 / $2,613.98
| Professional | | $1,249.90 | $1,853.85 | $2,613.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $923.64 / $1,250.04 / $2,770.92
| Facility | | $923.64 | $1,250.04 | $2,770.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,018.42 / $1,786.68 / $2,353.41
| Professional | | $1,018.42 | $1,786.68 | $2,353.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,063.58 / $2,063.33 / $2,353.41
| Professional | | $1,063.58 | $2,063.33 | $2,353.41 |