- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,490.50 / $1,765.31 / $9,307.62
| Professional | | $1,490.50 | $1,765.31 | $9,307.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,851.94 / $2,851.94 / $3,422.33
| Professional | | $2,851.94 | $2,851.94 | $3,422.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,851.94 / $2,851.94 / $2,851.94
| Facility | | $2,851.94 | $2,851.94 | $2,851.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,670.35 / $2,851.94 / $5,042.39
| Professional | | $1,670.35 | $2,851.94 | $5,042.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,758.04 / $2,365.31 / $3,236.50
| Facility | | $1,758.04 | $2,365.31 | $3,236.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,781.50 / $2,912.76 / $4,853.70
| Professional | | $1,781.50 | $2,912.76 | $4,853.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,393.44 / $3,003.52 / $3,803.84
| Professional | | $2,393.44 | $3,003.52 | $3,803.84 |