- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,402.35 / $1,847.11 / $2,040.00
| Professional | | $1,402.35 | $1,847.11 | $2,040.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,552.28 / $1,552.28 / $1,937.33
| Professional | | $1,552.28 | $1,552.28 | $1,937.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,473.40 / $1,601.52 / $1,601.52
| Professional | | $1,473.40 | $1,601.52 | $1,601.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,460.50 / $1,460.50 / $2,520.11
| Facility | | $1,460.50 | $1,460.50 | $2,520.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,241.43 / $1,460.50 / $2,994.75
| Professional | | $1,241.43 | $1,460.50 | $2,994.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $730.25 / $1,201.69 / $1,734.35
| Professional | | $730.25 | $1,201.69 | $1,734.35 |