- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,972.26 / $2,105.48 / $3,767.02
| Professional | | $1,972.26 | $2,105.48 | $3,767.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,931.60 / $2,931.60 / $3,294.12
| Professional | | $2,931.60 | $2,931.60 | $3,294.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,756.64 / $2,756.64 / $2,756.64
| Facility | | $2,756.64 | $2,756.64 | $2,756.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,012.35 / $2,012.35 / $2,012.35
| Professional | | $2,012.35 | $2,012.35 | $2,012.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,373.18 / $4,818.83 / $6,939.12
| Professional | | $3,373.18 | $4,818.83 | $6,939.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,865.35 / $2,404.07 / $3,832.05
| Professional | | $1,865.35 | $2,404.07 | $3,832.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,643.02 / $2,643.02 / $3,373.18
| Professional | | $2,643.02 | $2,643.02 | $3,373.18 |