- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,519.86 / $3,711.17 / $4,905.60
| Professional | | $2,519.86 | $3,711.17 | $4,905.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,976.17 / $2,976.17 / $3,995.08
| Professional | | $2,976.17 | $2,976.17 | $3,995.08 |
- 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
- $435.92 / $3,657.49 / $3,657.49
| Professional | | $435.92 | $3,657.49 | $3,657.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,531.46 / $3,316.00 / $5,512.32
| Facility | | $2,531.46 | $3,316.00 | $5,512.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,704.57 / $2,406.44 / $4,332.30
| Professional | | $1,704.57 | $2,406.44 | $4,332.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,586.57 / $2,151.40 / $4,335.17
| Professional | | $1,586.57 | $2,151.40 | $4,335.17 |