- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,563.10 / $2,787.84 / $3,107.26
| Professional | | $2,563.10 | $2,787.84 | $3,107.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,077.48 / $2,077.48 / $2,288.06
| Professional | | $2,077.48 | $2,077.48 | $2,288.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,592.00 / $2,592.00 / $2,592.00
| Facility | | $2,592.00 | $2,592.00 | $2,592.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,203.19 / $2,592.00 / $3,055.80
| Professional | | $2,203.19 | $2,592.00 | $3,055.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,646.16 / $2,646.16 / $2,646.16
| Professional | | $2,646.16 | $2,646.16 | $2,646.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,216.27 / $1,543.92 / $2,256.32
| Professional | | $1,216.27 | $1,543.92 | $2,256.32 |