- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,153.17 / $1,850.44 / $2,036.14
| Professional | | $1,153.17 | $1,850.44 | $2,036.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,564.36 / $1,977.93 / $2,074.35
| Professional | | $1,564.36 | $1,977.93 | $2,074.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,414.26 / $1,414.26 / $1,414.26
| Facility | | $1,414.26 | $1,414.26 | $1,414.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.28 / $1,414.26 / $1,760.73
| Professional | | $213.28 | $1,414.26 | $1,760.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,287.26 / $2,456.58 / $12,643.10
| Facility | | $1,287.26 | $2,456.58 | $12,643.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,056.76 / $1,606.92 / $2,867.55
| Professional | | $1,056.76 | $1,606.92 | $2,867.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,194.83 / $1,609.08 / $2,893.09
| Professional | | $1,194.83 | $1,609.08 | $2,893.09 |