- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,819.70 / $2,884.03
| Professional | | $1,479.11 | $1,819.70 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $2,570.40 / $2,570.40
| Professional | | $2,570.40 | $2,570.40 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,238.72 / $5,495.41
| Facility | | $2,238.72 | $2,238.72 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,621.81 / $3,981.07
| Professional | | $1,621.81 | $1,621.81 | $3,981.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,290.87 / $4,168.69
| Facility | | $2,041.74 | $2,290.87 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,584.89 / $2,344.23
| Professional | | $1,023.29 | $1,584.89 | $2,344.23 |