- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,005.73 / $1,122.85 / $4,727.51
| Professional | | $1,005.73 | $1,122.85 | $4,727.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,098.32 / $1,125.84 / $1,510.00
| Professional | | $1,098.32 | $1,125.84 | $1,510.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,076.35 / $3,076.35 / $3,076.35
| Facility | | $3,076.35 | $3,076.35 | $3,076.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $969.14 / $1,357.82 / $2,644.01
| Professional | | $969.14 | $1,357.82 | $2,644.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,053.55 / $1,401.22 / $2,350.07
| Professional | | $1,053.55 | $1,401.22 | $2,350.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $905.54 / $1,194.59 / $2,050.98
| Professional | | $905.54 | $1,194.59 | $2,050.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $925.28 / $1,211.58 / $1,497.84
| Professional | | $925.28 | $1,211.58 | $1,497.84 |