- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,137.96 / $2,137.96
| Professional | | $1,995.26 | $2,137.96 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $2,570.40 / $2,570.40
| Professional | | $1,621.81 | $2,570.40 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,187.76 / $2,238.72
| Facility | | $2,187.76 | $2,187.76 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,187.76 / $2,238.72
| Professional | | $1,862.09 | $2,187.76 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $288.40 / $2,290.87 / $3,090.30
| Facility | | $288.40 | $2,290.87 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,344.23 / $3,981.07
| Professional | | $1,819.70 | $2,344.23 | $3,981.07 |