- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,818.16 / $3,055.86 / $4,092.68
| Professional | | $2,818.16 | $3,055.86 | $4,092.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,390.57 / $3,390.57 / $3,390.57
| Professional | | $3,390.57 | $3,390.57 | $3,390.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.69 / $2,290.69 / $3,236.31
| Facility | | $2,290.69 | $2,290.69 | $3,236.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,947.10 / $2,290.69 / $3,236.31
| Professional | | $1,947.10 | $2,290.69 | $3,236.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.69 / $2,290.69 / $3,236.31
| Facility | | $2,290.69 | $2,290.69 | $3,236.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.69 / $2,290.69 / $3,236.31
| Professional | | $2,290.69 | $2,290.69 | $3,236.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $204.97 / $242.43 / $2,383.14
| Facility | | $204.97 | $242.43 | $2,383.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $923.73 / $2,332.80 / $3,641.40
| Professional | | $923.73 | $2,332.80 | $3,641.40 |