- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,104.37 / $3,025.03 / $4,121.05
| Professional | | $2,104.37 | $3,025.03 | $4,121.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,997.00 / $2,230.86 / $3,597.80
| Professional | | $1,997.00 | $2,230.86 | $3,597.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,446.40 / $2,446.40 / $2,792.28
| Facility | | $2,446.40 | $2,446.40 | $2,792.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,079.44 / $2,446.40 / $3,210.83
| Professional | | $2,079.44 | $2,446.40 | $3,210.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $272.55 / $2,718.32 / $4,847.72
| Facility | | $272.55 | $2,718.32 | $4,847.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,435.76 / $2,080.07 / $3,997.50
| Professional | | $1,435.76 | $2,080.07 | $3,997.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,415.58 / $1,649.05 / $3,786.84
| Professional | | $1,415.58 | $1,649.05 | $3,786.84 |