- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,658.44 / $9,220.69 / $9,220.69
| Professional | | $2,658.44 | $9,220.69 | $9,220.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,918.11 / $2,918.11 / $2,918.11
| Professional | | $2,918.11 | $2,918.11 | $2,918.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,084.13 / $3,137.55 / $3,137.55
| Facility | | $2,084.13 | $3,137.55 | $3,137.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,084.13 / $2,551.48 / $3,137.55
| Professional | | $2,084.13 | $2,551.48 | $3,137.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,535.70 / $2,988.14 / $3,137.55
| Facility | | $1,535.70 | $2,988.14 | $3,137.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,084.13 / $2,354.87 / $3,139.82
| Professional | | $2,084.13 | $2,354.87 | $3,139.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,070.48 / $2,070.48 / $2,175.80
| Facility | | $2,070.48 | $2,070.48 | $2,175.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,242.02 / $1,374.19 / $2,117.59
| Professional | | $1,242.02 | $1,374.19 | $2,117.59 |