- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,757.14 / $2,308.98 / $3,861.57
| Professional | | $1,757.14 | $2,308.98 | $3,861.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,563.67 / $2,563.67 / $2,859.15
| Professional | | $2,563.67 | $2,563.67 | $2,859.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,569.13 / $2,569.13 / $2,569.13
| Facility | | $2,569.13 | $2,569.13 | $2,569.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,183.76 / $2,183.76 / $2,183.76
| Professional | | $2,183.76 | $2,183.76 | $2,183.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.36 / $208.66 / $341.12
| Professional | | $177.36 | $208.66 | $341.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,539.19 / $2,539.19 / $2,733.10
| Professional | | $2,539.19 | $2,539.19 | $2,733.10 |