- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,567.12 / $1,894.77 / $3,089.42
| Professional | | $1,567.12 | $1,894.77 | $3,089.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,072.00 / $2,165.44 / $2,641.45
| Professional | | $2,072.00 | $2,165.44 | $2,641.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,782.58 / $2,782.58 / $2,782.58
| Facility | | $2,782.58 | $2,782.58 | $2,782.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,031.28 / $2,031.28 / $2,031.28
| Professional | | $2,031.28 | $2,031.28 | $2,031.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,704.84 / $3,864.06 / $5,564.25
| Professional | | $2,704.84 | $3,864.06 | $5,564.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,692.48 / $2,024.12 / $3,056.86
| Professional | | $1,692.48 | $2,024.12 | $3,056.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,052.83 / $2,052.83 / $2,704.84
| Professional | | $2,052.83 | $2,052.83 | $2,704.84 |