- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.82 / $1,642.35 / $2,135.56
| Professional | | $1,412.82 | $1,642.35 | $2,135.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,328.00 / $1,695.68 / $2,528.17
| Professional | | $1,328.00 | $1,695.68 | $2,528.17 |
- 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
- $1,695.43 / $2,380.90 / $2,849.75
| Professional | | $1,695.43 | $2,380.90 | $2,849.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,618.71 / $1,872.85 / $2,873.05
| Professional | | $1,618.71 | $1,872.85 | $2,873.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,361.75 / $1,624.75 / $2,459.32
| Professional | | $1,361.75 | $1,624.75 | $2,459.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,292.00 / $1,964.95 / $3,616.82
| Professional | | $1,292.00 | $1,964.95 | $3,616.82 |