- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,300.62 / $2,300.62 / $2,654.56
| Professional | | $2,300.62 | $2,300.62 | $2,654.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,814.21 / $3,814.21 / $3,814.21
| Professional | | $3,814.21 | $3,814.21 | $3,814.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,886.72 / $2,886.72 / $3,465.09
| Facility | | $2,886.72 | $2,886.72 | $3,465.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,107.31 / $2,687.21 / $3,077.39
| Professional | | $2,107.31 | $2,687.21 | $3,077.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,886.72 / $2,886.72 / $3,465.09
| Facility | | $2,886.72 | $2,886.72 | $3,465.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,107.31 / $2,886.72 / $3,077.39
| Professional | | $2,107.31 | $2,886.72 | $3,077.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,568.00 / $3,243.48 / $5,450.16
| Professional | | $1,568.00 | $3,243.48 | $5,450.16 |