- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,960.35 / $2,487.00 / $3,504.63
| Professional | | $1,960.35 | $2,487.00 | $3,504.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,976.17 / $4,302.80 / $4,302.80
| Professional | | $2,976.17 | $4,302.80 | $4,302.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,658.56 / $3,657.49 / $3,657.49
| Facility | | $2,658.56 | $3,657.49 | $3,657.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $390.93 / $3,657.49 / $5,767.50
| Professional | | $390.93 | $3,657.49 | $5,767.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,652.80 / $3,307.19 / $4,679.30
| Facility | | $2,652.80 | $3,307.19 | $4,679.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,730.02 / $3,730.02 / $3,730.02
| Professional | | $3,730.02 | $3,730.02 | $3,730.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,866.56 / $1,993.92 / $2,783.42
| Professional | | $1,866.56 | $1,993.92 | $2,783.42 |