- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,657.46 / $1,657.46 / $1,685.44
| Professional | | $1,657.46 | $1,657.46 | $1,685.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,058.64 / $1,370.00 / $2,056.98
| Professional | | $1,058.64 | $1,370.00 | $2,056.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $814.23 / $814.23 / $814.23
| Facility | | $814.23 | $814.23 | $814.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,339.23 / $1,970.72 / $2,358.80
| Professional | | $1,339.23 | $1,970.72 | $2,358.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,326.46 / $1,534.71 / $2,354.33
| Professional | | $1,326.46 | $1,534.71 | $2,354.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,657.46 / $1,657.46 / $1,657.46
| Professional | | $1,657.46 | $1,657.46 | $1,657.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,039.73 / $1,492.71 / $1,936.88
| Professional | | $1,039.73 | $1,492.71 | $1,936.88 |