- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,570.40 / $6,606.93
| Professional | | $2,290.87 | $2,570.40 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $2,818.38 / $3,467.37
| Professional | | $2,570.40 | $2,818.38 | $3,467.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $512.86 / $512.86 / $645.65
| Facility | | $512.86 | $512.86 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $3,235.94 / $5,623.41
| Professional | | $2,344.23 | $3,235.94 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,570.40 / $4,365.16
| Professional | | $2,290.87 | $2,570.40 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,344.23 / $4,073.80
| Facility | | $1,995.26 | $2,344.23 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,818.38 / $5,011.87
| Professional | | $2,041.74 | $2,818.38 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,754.23 / $3,467.37
| Professional | | $2,398.83 | $2,754.23 | $3,467.37 |