- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,782.66 / $9,651.53 / $9,651.53
| Professional | | $2,782.66 | $9,651.53 | $9,651.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,383.65 / $3,383.65 / $3,383.65
| Professional | | $3,383.65 | $3,383.65 | $3,383.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,217.07 / $3,638.10 / $3,638.10
| Facility | | $2,217.07 | $3,638.10 | $3,638.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,217.07 / $2,958.54 / $3,638.10
| Professional | | $2,217.07 | $2,958.54 | $3,638.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,706.96 / $3,464.86 / $3,638.10
| Facility | | $1,706.96 | $3,464.86 | $3,638.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,217.07 / $2,730.56 / $3,640.74
| Professional | | $2,217.07 | $2,730.56 | $3,640.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,301.38 / $2,301.38 / $2,418.44
| Facility | | $2,301.38 | $2,301.38 | $2,418.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.52 / $1,527.44 / $2,353.73
| Professional | | $1,380.52 | $1,527.44 | $2,353.73 |