- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,055.19 / $1,872.47 / $1,918.08
| Professional | | $1,055.19 | $1,872.47 | $1,918.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,211.70 / $1,556.17 / $2,413.07
| Professional | | $1,211.70 | $1,556.17 | $2,413.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,005.81 / $1,005.81 / $1,005.81
| Facility | | $1,005.81 | $1,005.81 | $1,005.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,614.35 / $2,362.67 / $2,994.64
| Professional | | $1,614.35 | $2,362.67 | $2,994.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,544.10 / $1,786.52 / $2,740.62
| Professional | | $1,544.10 | $1,786.52 | $2,740.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $946.28 / $1,055.19 / $1,918.08
| Professional | | $946.28 | $1,055.19 | $1,918.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,198.60 / $1,605.12 / $2,402.62
| Professional | | $1,198.60 | $1,605.12 | $2,402.62 |