- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,087.74 / $1,297.64 / $2,144.77
| Professional | | $1,087.74 | $1,297.64 | $2,144.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,080.00 / $1,276.03 / $1,501.42
| Professional | | $1,080.00 | $1,276.03 | $1,501.42 |
- 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
- $1,025.22 / $1,510.92 / $3,071.95
| Professional | | $1,025.22 | $1,510.92 | $3,071.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,219.57 / $1,573.25 / $2,677.44
| Professional | | $1,219.57 | $1,573.25 | $2,677.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $942.80 / $1,355.28 / $2,441.60
| Professional | | $942.80 | $1,355.28 | $2,441.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $897.63 / $1,402.51 / $1,733.01
| Professional | | $897.63 | $1,402.51 | $1,733.01 |