- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,478.74 / $1,478.74 / $1,662.41
| Professional | | $1,478.74 | $1,478.74 | $1,662.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,388.28 / $1,535.54 / $2,348.57
| Professional | | $1,388.28 | $1,535.54 | $2,348.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,384.04 / $1,719.73 / $2,463.81
| Professional | | $1,384.04 | $1,719.73 | $2,463.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,277.16 / $1,644.88 / $2,523.34
| Professional | | $1,277.16 | $1,644.88 | $2,523.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,478.74 / $1,478.74 / $1,662.41
| Professional | | $1,478.74 | $1,478.74 | $1,662.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,167.24 / $10,167.24 / $10,167.24
| Facility | | $10,167.24 | $10,167.24 | $10,167.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,395.04 / $1,826.13 / $2,275.91
| Professional | | $1,395.04 | $1,826.13 | $2,275.91 |