- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.89 / $3,162.28 / $7,585.78
| Professional | | $2,511.89 | $3,162.28 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,019.95 / $3,388.44 / $4,073.80
| Professional | | $3,019.95 | $3,388.44 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $3,981.07 / $6,918.31
| Professional | | $2,570.40 | $3,981.07 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,630.27 / $3,019.95 / $5,495.41
| Professional | | $2,630.27 | $3,019.95 | $5,495.41 |
- 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
- $2,290.87 / $3,235.94 / $5,495.41
| Professional | | $2,290.87 | $3,235.94 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $3,388.44 / $3,981.07
| Professional | | $2,570.40 | $3,388.44 | $3,981.07 |