- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,298.42 / $2,852.04 / $4,572.45
| Professional | | $2,298.42 | $2,852.04 | $4,572.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,926.39 / $3,060.08 / $3,732.74
| Professional | | $2,926.39 | $3,060.08 | $3,732.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,728.42 / $3,728.42 / $3,728.42
| Facility | | $3,728.42 | $3,728.42 | $3,728.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,721.75 / $2,721.75 / $3,728.42
| Professional | | $2,721.75 | $2,721.75 | $3,728.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,822.32 / $5,460.46 / $7,863.06
| Professional | | $3,822.32 | $5,460.46 | $7,863.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,562.50 / $2,869.62 / $4,319.78
| Professional | | $2,562.50 | $2,869.62 | $4,319.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,053.28 / $3,053.28 / $3,822.32
| Professional | | $3,053.28 | $3,053.28 | $3,822.32 |