- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,125.48 / $2,419.58 / $2,491.81
| Professional | | $2,125.48 | $2,419.58 | $2,491.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,512.03 / $2,527.92 / $3,129.41
| Professional | | $2,512.03 | $2,527.92 | $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 / $4,729.50
| Professional | | $2,271.73 | $2,672.64 | $4,729.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,059.60 / $3,059.60 / $3,059.60
| Professional | | $3,059.60 | $3,059.60 | $3,059.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.26 / $2,047.28 / $3,412.13
| Professional | | $1,584.26 | $2,047.28 | $3,412.13 |