- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,390.91 / $2,799.86 / $3,035.87
| Professional | | $2,390.91 | $2,799.86 | $3,035.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,230.86 / $2,230.86 / $2,230.86
| Professional | | $2,230.86 | $2,230.86 | $2,230.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,446.40 / $2,446.40 / $2,446.40
| Facility | | $2,446.40 | $2,446.40 | $2,446.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $286.94 / $2,079.44 / $2,446.40
| Professional | | $286.94 | $2,079.44 | $2,446.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,862.23 / $8,034.57 / $10,183.53
| Professional | | $2,862.23 | $8,034.57 | $10,183.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $983.97 / $1,475.96 / $3,397.88
| Professional | | $983.97 | $1,475.96 | $3,397.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,995.74 / $3,319.22 / $4,224.46
| Professional | | $2,995.74 | $3,319.22 | $4,224.46 |