- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,012.05 / $1,224.55 / $1,247.58
| Professional | | $1,012.05 | $1,224.55 | $1,247.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.39 / $1,386.51 / $2,122.98
| Professional | | $1,071.39 | $1,386.51 | $2,122.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $611.00 / $611.00 / $1,168.74
| Facility | | $611.00 | $611.00 | $1,168.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $929.62 / $1,482.69 / $2,232.62
| Professional | | $929.62 | $1,482.69 | $2,232.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,151.63 / $1,483.20 / $2,320.96
| Professional | | $1,151.63 | $1,483.20 | $2,320.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,012.05 / $1,224.55 / $2,409.52
| Professional | | $1,012.05 | $1,224.55 | $2,409.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $997.36 / $1,462.15 / $2,008.89
| Professional | | $997.36 | $1,462.15 | $2,008.89 |