- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,799.86 / $3,035.87 / $4,065.90
| Professional | | $2,799.86 | $3,035.87 | $4,065.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,612.84 / $3,612.84 / $3,612.84
| Professional | | $3,612.84 | $3,612.84 | $3,612.84 |
- 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
- $2,079.44 / $2,446.40 / $2,519.79
| Professional | | $2,079.44 | $2,446.40 | $2,519.79 |
- 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
- $2,446.40 / $2,446.40 / $2,519.79
| Professional | | $2,446.40 | $2,446.40 | $2,519.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $983.97 / $2,168.48 / $3,617.70
| Professional | | $983.97 | $2,168.48 | $3,617.70 |