- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,549.32 / $2,549.32 / $2,941.52
| Professional | | $2,549.32 | $2,549.32 | $2,941.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,226.53 / $4,226.53 / $4,226.53
| Professional | | $4,226.53 | $4,226.53 | $4,226.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,780.72 / $2,780.72 / $3,839.67
| Facility | | $2,780.72 | $2,780.72 | $3,839.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,029.93 / $2,780.72 / $2,964.38
| Professional | | $2,029.93 | $2,780.72 | $2,964.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,780.72 / $2,780.72 / $3,839.67
| Facility | | $2,780.72 | $2,780.72 | $3,839.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,029.93 / $2,780.72 / $2,964.38
| Professional | | $2,029.93 | $2,780.72 | $2,964.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.50 / $3,345.05 / $6,039.34
| Professional | | $1,737.50 | $3,345.05 | $6,039.34 |