- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,632.40 / $1,632.40 / $1,883.54
| Professional | | $1,632.40 | $1,632.40 | $1,883.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,706.36 / $2,706.36 / $2,706.36
| Professional | | $2,706.36 | $2,706.36 | $2,706.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,217.07 / $2,217.07 / $2,458.64
| Facility | | $2,217.07 | $2,217.07 | $2,458.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,618.46 / $1,906.95 / $2,363.51
| Professional | | $1,618.46 | $1,906.95 | $2,363.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,217.07 / $2,217.07 / $2,458.64
| Facility | | $2,217.07 | $2,217.07 | $2,458.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,618.46 / $2,217.07 / $2,363.51
| Professional | | $1,618.46 | $2,217.07 | $2,363.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,018.42 / $2,018.42 / $2,418.44
| Facility | | $2,018.42 | $2,018.42 | $2,418.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,112.57 / $2,301.38 / $3,867.14
| Professional | | $1,112.57 | $2,301.38 | $3,867.14 |