- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,072.81 / $1,284.56 / $1,834.92
| Professional | | $1,072.81 | $1,284.56 | $1,834.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,142.73 / $1,458.61 / $2,174.55
| Professional | | $1,142.73 | $1,458.61 | $2,174.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $712.05 / $712.05 / $712.05
| Facility | | $712.05 | $712.05 | $712.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,407.44 / $2,046.42 / $2,449.40
| Professional | | $1,407.44 | $2,046.42 | $2,449.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,392.41 / $1,611.02 / $2,471.39
| Professional | | $1,392.41 | $1,611.02 | $2,471.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,034.03 / $1,247.08 / $1,805.47
| Professional | | $1,034.03 | $1,247.08 | $1,805.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,088.77 / $1,609.01 / $2,088.61
| Professional | | $1,088.77 | $1,609.01 | $2,088.61 |