- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $3,311.31 / $7,762.47
| Professional | | $2,570.40 | $3,311.31 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $3,019.95 / $3,715.35
| Professional | | $2,754.23 | $3,019.95 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $3,715.35 / $7,244.36
| Professional | | $2,454.71 | $3,715.35 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $2,951.21 / $5,011.87
| Professional | | $2,570.40 | $2,951.21 | $5,011.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $660.69 / $660.69 / $660.69
| Facility | | $660.69 | $660.69 | $660.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $3,162.28 / $5,623.41
| Professional | | $2,238.72 | $3,162.28 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $3,311.31 / $3,890.45
| Professional | | $2,290.87 | $3,311.31 | $3,890.45 |