- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.89 / $3,548.13 / $3,981.07
| Professional | | $2,511.89 | $3,548.13 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,951.21 / $4,265.80
| Professional | | $2,398.83 | $2,951.21 | $4,265.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,691.53 / $2,691.53 / $3,162.28
| Facility | | $2,691.53 | $2,691.53 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,691.53 / $3,235.94
| Professional | | $2,290.87 | $2,691.53 | $3,235.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $288.40 / $3,388.44 / $5,370.32
| Facility | | $288.40 | $3,388.44 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $2,137.96 / $4,466.84
| Professional | | $1,584.89 | $2,137.96 | $4,466.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $234.42 / $524.81 / $3,235.94
| Facility | | $234.42 | $524.81 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $1,949.84 / $3,981.07
| Professional | | $1,584.89 | $1,949.84 | $3,981.07 |