- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,078.92 / $1,318.54 / $5,571.92
| Professional | | $1,078.92 | $1,318.54 | $5,571.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,070.00 / $1,184.36 / $1,395.64
| Professional | | $1,070.00 | $1,184.36 | $1,395.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,076.35 / $3,076.35 / $3,076.35
| Facility | | $3,076.35 | $3,076.35 | $3,076.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $943.88 / $1,388.08 / $2,849.94
| Professional | | $943.88 | $1,388.08 | $2,849.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,129.03 / $1,456.45 / $2,487.29
| Professional | | $1,129.03 | $1,456.45 | $2,487.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $880.16 / $1,170.42 / $2,115.53
| Professional | | $880.16 | $1,170.42 | $2,115.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $829.01 / $1,298.38 / $1,604.19
| Professional | | $829.01 | $1,298.38 | $1,604.19 |