- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,202.26 / $2,187.76
| Professional | | $1,047.13 | $1,202.26 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,202.26 / $1,737.80
| Professional | | $1,071.52 | $1,202.26 | $1,737.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $575.44 / $602.56 / $1,905.46
| Facility | | $575.44 | $602.56 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,380.38 / $2,344.23
| Professional | | $954.99 | $1,380.38 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,230.27 / $1,698.24
| Professional | | $933.25 | $1,230.27 | $1,698.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $302.00 / $416.87 / $1,096.48
| Facility | | $302.00 | $416.87 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,348.96 / $2,238.72
| Professional | | $1,000.00 | $1,348.96 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,380.38 / $1,584.89
| Professional | | $1,000.00 | $1,380.38 | $1,584.89 |