- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,387.55 / $2,143.96 / $2,811.32
| Professional | | $1,387.55 | $2,143.96 | $2,811.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,873.65 / $2,269.10 / $3,345.88
| Professional | | $1,873.65 | $2,269.10 | $3,345.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,988.73 / $2,469.02 / $3,867.34
| Professional | | $1,988.73 | $2,469.02 | $3,867.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,945.93 / $2,506.19 / $3,844.63
| Professional | | $1,945.93 | $2,506.19 | $3,844.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,387.55 / $1,560.52 / $2,143.96
| Professional | | $1,387.55 | $1,560.52 | $2,143.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,831.32 / $11,831.32 / $11,831.32
| Facility | | $11,831.32 | $11,831.32 | $11,831.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,868.88 / $2,112.56 / $3,337.38
| Professional | | $1,868.88 | $2,112.56 | $3,337.38 |