- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,853.81 / $2,347.01 / $3,865.63
| Professional | | $1,853.81 | $2,347.01 | $3,865.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,386.00 / $2,386.00 / $3,042.10
| Professional | | $2,386.00 | $2,386.00 | $3,042.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,780.72 / $2,780.72 / $2,780.72
| Facility | | $2,780.72 | $2,780.72 | $2,780.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,029.93 / $2,029.93 / $2,780.72
| Professional | | $2,029.93 | $2,029.93 | $2,780.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,115.11 / $4,450.14 / $6,408.22
| Professional | | $3,115.11 | $4,450.14 | $6,408.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,004.58 / $2,296.50 / $3,520.52
| Professional | | $2,004.58 | $2,296.50 | $3,520.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,692.82 / $2,692.82 / $3,115.11
| Professional | | $2,692.82 | $2,692.82 | $3,115.11 |