- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,554.14 / $1,836.27 / $9,682.86
| Professional | | $1,554.14 | $1,836.27 | $9,682.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,949.74 / $2,949.74 / $3,539.69
| Professional | | $2,949.74 | $2,949.74 | $3,539.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,949.74 / $2,949.74 / $2,949.74
| Facility | | $2,949.74 | $2,949.74 | $2,949.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,732.05 / $2,948.82 / $5,285.50
| Professional | | $1,732.05 | $2,948.82 | $5,285.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,817.03 / $2,422.29 / $3,381.35
| Facility | | $1,817.03 | $2,422.29 | $3,381.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,845.93 / $3,020.60 / $5,033.39
| Professional | | $1,845.93 | $3,020.60 | $5,033.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,575.59 / $3,132.80 / $3,955.42
| Professional | | $2,575.59 | $3,132.80 | $3,955.42 |