- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,290.87 / $5,495.41
| Professional | | $1,778.28 | $2,290.87 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,691.53 / $3,311.31
| Professional | | $2,398.83 | $2,691.53 | $3,311.31 |
- 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
- $1,949.84 / $2,511.89 / $5,370.32
| Professional | | $1,949.84 | $2,511.89 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $2,691.53 / $4,168.69
| Professional | | $2,344.23 | $2,691.53 | $4,168.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,187.76 / $4,073.80
| Facility | | $1,995.26 | $2,187.76 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $2,454.71 / $4,677.35
| Professional | | $1,659.59 | $2,454.71 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,818.38 / $3,630.78
| Professional | | $1,905.46 | $2,818.38 | $3,630.78 |