- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.46 / $2,089.46 / $2,410.92
| Professional | | $2,089.46 | $2,089.46 | $2,410.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,464.14 / $3,464.14 / $3,464.14
| Professional | | $3,464.14 | $3,464.14 | $3,464.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,448.80 / $2,448.80 / $3,147.06
| Facility | | $2,448.80 | $2,448.80 | $3,147.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,787.62 / $2,440.73 / $2,871.59
| Professional | | $1,787.62 | $2,440.73 | $2,871.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,448.80 / $2,448.80 / $3,147.06
| Facility | | $2,448.80 | $2,448.80 | $3,147.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,787.62 / $2,448.80 / $2,871.59
| Professional | | $1,787.62 | $2,448.80 | $2,871.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,424.09 / $2,945.77 / $4,949.93
| Professional | | $1,424.09 | $2,945.77 | $4,949.93 |