- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,851.26 / $2,661.19 / $3,625.39
| Professional | | $1,851.26 | $2,661.19 | $3,625.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,077.48 / $2,077.48 / $3,016.34
| Professional | | $2,077.48 | $2,077.48 | $3,016.34 |
- 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
- Facility
- Modifier
- Low / Median / High Price
- $224.92 / $1,851.26 / $3,307.70
| Facility | | $224.92 | $1,851.26 | $3,307.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,272.25 / $1,836.01 / $3,239.24
| Professional | | $1,272.25 | $1,836.01 | $3,239.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,177.96 / $1,613.80 / $3,157.60
| Professional | | $1,177.96 | $1,613.80 | $3,157.60 |