- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,591.15 / $1,722.25 / $2,673.36
| Professional | | $1,591.15 | $1,722.25 | $2,673.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,852.72 / $3,157.12 / $3,157.12
| Professional | | $2,852.72 | $3,157.12 | $3,157.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,434.80 / $2,671.66 / $2,671.66
| Facility | | $2,434.80 | $2,671.66 | $2,671.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $286.64 / $2,671.66 / $4,515.00
| Professional | | $286.64 | $2,671.66 | $4,515.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $366.21 / $2,391.12 / $3,622.30
| Facility | | $366.21 | $2,391.12 | $3,622.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,953.00 / $2,953.00 / $2,953.00
| Professional | | $2,953.00 | $2,953.00 | $2,953.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,361.32 / $1,575.56 / $2,155.42
| Professional | | $1,361.32 | $1,575.56 | $2,155.42 |