- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,285.81 / $1,598.65 / $1,947.71
| Professional | | $1,285.81 | $1,598.65 | $1,947.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,606.07 / $2,078.44 / $2,941.16
| Professional | | $1,606.07 | $2,078.44 | $2,941.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,560.42 / $2,337.25 / $3,300.78
| Professional | | $1,560.42 | $2,337.25 | $3,300.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,920.85 / $2,222.42 / $3,409.32
| Professional | | $1,920.85 | $2,222.42 | $3,409.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,285.81 / $1,838.14 / $1,947.71
| Professional | | $1,285.81 | $1,838.14 | $1,947.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $25,733.64 / $25,733.64 / $25,733.64
| Facility | | $25,733.64 | $25,733.64 | $25,733.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,480.26 / $2,103.94 / $3,044.09
| Professional | | $1,480.26 | $2,103.94 | $3,044.09 |