- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,629.40 / $2,354.80 / $3,701.39
| Professional | | $1,629.40 | $2,354.80 | $3,701.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,054.10 / $2,670.33 / $2,670.33
| Professional | | $2,054.10 | $2,670.33 | $2,670.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,360.51 / $3,360.51 / $3,360.51
| Facility | | $3,360.51 | $3,360.51 | $3,360.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,472.88 / $1,472.88 / $1,472.88
| Professional | | $1,472.88 | $1,472.88 | $1,472.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,681.16 / $1,962.23 / $2,484.39
| Professional | | $1,681.16 | $1,962.23 | $2,484.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $175.58 / $405.17 / $2,628.63
| Professional | | $175.58 | $405.17 | $2,628.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,467.23 / $1,467.23 / $1,786.62
| Professional | | $1,467.23 | $1,467.23 | $1,786.62 |