- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,180.60 / $2,859.93 / $3,258.99
| Professional | | $2,180.60 | $2,859.93 | $3,258.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,128.72 / $3,400.78 / $3,400.78
| Professional | | $3,128.72 | $3,400.78 | $3,400.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,214.83 / $2,214.83 / $2,214.83
| Facility | | $2,214.83 | $2,214.83 | $2,214.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,592.00 / $2,592.00 / $2,618.46
| Facility | | $2,592.00 | $2,592.00 | $2,618.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $267.95 / $2,592.00 / $3,993.75
| Professional | | $267.95 | $2,592.00 | $3,993.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,064.77 / $1,543.92 / $2,342.64
| Professional | | $1,064.77 | $1,543.92 | $2,342.64 |