- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.04 / $3,129.41 / $3,214.07
| Professional | | $2,454.04 | $3,129.41 | $3,214.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,257.26 / $3,129.41 / $3,129.41
| Professional | | $2,257.26 | $3,129.41 | $3,129.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,672.64 / $2,672.64 / $2,672.64
| Facility | | $2,672.64 | $2,672.64 | $2,672.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,271.73 / $2,672.64 / $2,672.64
| Professional | | $2,271.73 | $2,672.64 | $2,672.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,406.89 / $2,651.66 / $3,753.11
| Professional | | $2,406.89 | $2,651.66 | $3,753.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,574.43 / $2,047.28 / $3,618.91
| Professional | | $1,574.43 | $2,047.28 | $3,618.91 |