- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,137.96 / $5,888.44
| Professional | | $1,778.28 | $2,137.96 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,137.96 / $2,570.40
| Professional | | $1,905.46 | $2,137.96 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,454.71 / $5,370.32
| Professional | | $1,819.70 | $2,454.71 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,041.74 / $3,235.94
| Professional | | $1,778.28 | $2,041.74 | $3,235.94 |
- 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
- $1,621.81 / $2,238.72 / $3,801.89
| Professional | | $1,621.81 | $2,238.72 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $2,290.87 / $2,630.27
| Professional | | $1,548.82 | $2,290.87 | $2,630.27 |