- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,527.88 / $2,022.61 / $2,068.00
| Professional | | $1,527.88 | $2,022.61 | $2,068.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,623.86 / $1,910.52 / $1,910.52
| Professional | | $1,623.86 | $1,910.52 | $1,910.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $192.60 / $1,436.52 / $1,436.52
| Facility | | $192.60 | $1,436.52 | $1,436.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,221.04 / $1,221.04 / $1,221.04
| Professional | | $1,221.04 | $1,221.04 | $1,221.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,485.94 / $1,485.94 / $1,485.94
| Professional | | $1,485.94 | $1,485.94 | $1,485.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $828.88 / $1,197.07 / $1,608.86
| Professional | | $828.88 | $1,197.07 | $1,608.86 |