- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,255.63 / $2,255.63 / $2,271.66
| Professional | | $2,255.63 | $2,255.63 | $2,271.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,448.80 / $1,832.39 / $2,867.07
| Professional | | $1,448.80 | $1,832.39 | $2,867.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,588.54 / $1,588.54 / $1,588.54
| Facility | | $1,588.54 | $1,588.54 | $1,588.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,850.19 / $2,761.39 / $3,305.16
| Professional | | $1,850.19 | $2,761.39 | $3,305.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,846.24 / $2,136.10 / $3,276.89
| Professional | | $1,846.24 | $2,136.10 | $3,276.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,255.63 / $2,255.63 / $2,255.63
| Professional | | $2,255.63 | $2,255.63 | $2,255.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,200.24 / $1,972.87 / $2,551.13
| Professional | | $1,200.24 | $1,972.87 | $2,551.13 |