- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,479.11 / $2,570.40
| Professional | | $1,202.26 | $1,479.11 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,995.26 / $3,090.30
| Professional | | $1,230.27 | $1,995.26 | $3,090.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $691.83 / $691.83 / $2,238.72
| Facility | | $691.83 | $691.83 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,949.84 / $3,235.94
| Professional | | $1,122.02 | $1,949.84 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,290.87 / $3,890.45
| Professional | | $1,513.56 | $2,290.87 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,698.24 / $3,548.13
| Professional | | $1,230.27 | $1,698.24 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,905.46 / $2,951.21
| Professional | | $1,318.26 | $1,905.46 | $2,951.21 |