- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,731.60 / $2,125.48 / $2,889.06
| Professional | | $1,731.60 | $2,125.48 | $2,889.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,972.45 / $3,972.45 / $3,972.45
| Professional | | $3,972.45 | $3,972.45 | $3,972.45 |
- 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 / $2,271.73 / $2,752.82
| Professional | | $2,271.73 | $2,271.73 | $2,752.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,855.63 / $3,671.52 / $4,405.83
| Professional | | $2,855.63 | $3,671.52 | $4,405.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,553.41 / $2,100.13 / $3,353.92
| Professional | | $1,553.41 | $2,100.13 | $3,353.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,808.37 / $2,808.37 / $3,467.55
| Professional | | $2,808.37 | $2,808.37 | $3,467.55 |