- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,957.00 / $1,957.00 / $1,957.09
| Professional | | $1,957.00 | $1,957.00 | $1,957.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,263.45 / $1,582.68 / $2,503.37
| Professional | | $1,263.45 | $1,582.68 | $2,503.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,144.71 / $1,144.71 / $1,144.71
| Facility | | $1,144.71 | $1,144.71 | $1,144.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,611.17 / $2,415.60 / $2,891.28
| Professional | | $1,611.17 | $2,415.60 | $2,891.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,610.05 / $1,862.83 / $2,857.68
| Professional | | $1,610.05 | $1,862.83 | $2,857.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,957.00 / $1,957.00 / $1,957.00
| Professional | | $1,957.00 | $1,957.00 | $1,957.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,223.84 / $1,697.94 / $2,195.61
| Professional | | $1,223.84 | $1,697.94 | $2,195.61 |