- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,860.33 / $2,273.56 / $2,517.94
| Professional | | $1,860.33 | $2,273.56 | $2,517.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,715.58 / $1,715.58 / $1,976.30
| Professional | | $1,715.58 | $1,715.58 | $1,976.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,786.79 / $1,786.79 / $1,786.79
| Facility | | $1,786.79 | $1,786.79 | $1,786.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,518.77 / $1,786.79 / $1,786.79
| Professional | | $1,518.77 | $1,786.79 | $1,786.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,864.51 / $2,054.12 / $2,907.37
| Professional | | $1,864.51 | $2,054.12 | $2,907.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,153.51 / $1,576.58 / $2,765.53
| Professional | | $1,153.51 | $1,576.58 | $2,765.53 |