- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,857.07 / $2,042.77 / $2,785.61
| Professional | | $1,857.07 | $2,042.77 | $2,785.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,039.14 / $2,039.14 / $2,039.14
| Professional | | $2,039.14 | $2,039.14 | $2,039.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,983.42 / $3,983.42 / $3,983.42
| Facility | | $3,983.42 | $3,983.42 | $3,983.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,058.71 / $3,058.71 / $4,806.54
| Facility | | $3,058.71 | $3,058.71 | $4,806.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,058.71 / $3,983.42 / $7,209.81
| Facility | | $3,058.71 | $3,983.42 | $7,209.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,039.14 / $2,039.14 / $2,039.14
| Professional | | $2,039.14 | $2,039.14 | $2,039.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,875.28 / $1,875.28 / $2,123.77
| Professional | | $1,875.28 | $1,875.28 | $2,123.77 |