- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,318.26 / $2,454.71
| Professional | | $1,096.48 | $1,318.26 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,202.26 / $1,445.44
| Professional | | $1,071.52 | $1,202.26 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,479.11 / $2,818.38
| Professional | | $1,047.13 | $1,479.11 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,202.26 / $2,187.76
| Professional | | $1,071.52 | $1,202.26 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $660.69 / $660.69 / $660.69
| Facility | | $660.69 | $660.69 | $660.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,380.38 / $2,454.71
| Professional | | $1,023.29 | $1,380.38 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,258.93 / $1,659.59
| Professional | | $1,000.00 | $1,258.93 | $1,659.59 |