- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,691.53 / $4,466.84
| Professional | | $1,862.09 | $2,691.53 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,235.94 / $3,235.94 / $3,235.94
| Professional | | $3,235.94 | $3,235.94 | $3,235.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,548.13 / $3,548.13 / $7,943.28
| Facility | | $3,548.13 | $3,548.13 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $2,570.40 / $6,025.60
| Professional | | $2,570.40 | $2,570.40 | $6,025.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $3,311.31 / $5,888.44
| Facility | | $2,884.03 | $3,311.31 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $2,187.76 / $3,311.31
| Professional | | $1,445.44 | $2,187.76 | $3,311.31 |