- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,282.92 / $2,282.92 / $2,889.06
| Professional | | $2,282.92 | $2,282.92 | $2,889.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,250.47 / $4,250.47 / $5,115.03
| Professional | | $4,250.47 | $4,250.47 | $5,115.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,317.67 / $2,672.64 / $2,672.64
| Facility | | $2,317.67 | $2,672.64 | $2,672.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,271.73 / $2,672.64 / $3,507.84
| Professional | | $2,271.73 | $2,672.64 | $3,507.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,282.92 / $2,739.52 / $5,074.80
| Facility | | $2,282.92 | $2,739.52 | $5,074.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,855.18 / $3,855.18 / $3,855.18
| Professional | | $3,855.18 | $3,855.18 | $3,855.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,364.85 / $2,047.28 / $2,638.75
| Professional | | $1,364.85 | $2,047.28 | $2,638.75 |