- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,734.43 / $1,734.43 / $2,194.80
| Professional | | $1,734.43 | $1,734.43 | $2,194.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,825.00 / $1,916.25 / $2,300.84
| Professional | | $1,825.00 | $1,916.25 | $2,300.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,850.09 / $1,850.09 / $2,096.94
| Facility | | $1,850.09 | $1,850.09 | $2,096.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,572.58 / $1,572.58 / $3,648.75
| Professional | | $1,572.58 | $1,572.58 | $3,648.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,734.43 / $1,907.40 / $3,145.80
| Facility | | $1,734.43 | $1,907.40 | $3,145.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,076.00 / $2,076.00 / $2,076.00
| Professional | | $2,076.00 | $2,076.00 | $2,076.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,295.95 / $1,555.14 / $2,976.32
| Professional | | $1,295.95 | $1,555.14 | $2,976.32 |