- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,075.59 / $2,473.04 / $3,955.56
| Professional | | $2,075.59 | $2,473.04 | $3,955.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,649.69 / $2,826.34 / $3,447.62
| Professional | | $2,649.69 | $2,826.34 | $3,447.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,802.84 / $2,802.84 / $2,802.84
| Facility | | $2,802.84 | $2,802.84 | $2,802.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,382.41 / $2,382.41 / $2,802.84
| Professional | | $2,382.41 | $2,382.41 | $2,802.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,530.36 / $5,043.37 / $7,262.45
| Professional | | $3,530.36 | $5,043.37 | $7,262.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,271.81 / $2,602.64 / $3,989.83
| Professional | | $2,271.81 | $2,602.64 | $3,989.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,714.26 / $2,714.26 / $3,530.36
| Professional | | $2,714.26 | $2,714.26 | $3,530.36 |