- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,450.81 / $2,450.81 / $3,467.92
| Professional | | $2,450.81 | $2,450.81 | $3,467.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,393.13 / $2,632.44 / $3,033.82
| Professional | | $2,393.13 | $2,632.44 | $3,033.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,399.94 / $2,399.94 / $4,012.16
| Facility | | $2,399.94 | $2,399.94 | $4,012.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $326.16 / $2,399.94 / $2,697.57
| Professional | | $326.16 | $2,399.94 | $2,697.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,316.21 / $3,316.21 / $3,316.21
| Professional | | $3,316.21 | $3,316.21 | $3,316.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,732.58 / $2,450.81 / $3,467.92
| Professional | | $1,732.58 | $2,450.81 | $3,467.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,357.08 / $2,035.62 / $4,120.89
| Professional | | $1,357.08 | $2,035.62 | $4,120.89 |