- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,086.81 / $1,327.67 / $2,040.00
| Professional | | $1,086.81 | $1,327.67 | $2,040.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,583.30 / $1,583.30 / $1,765.79
| Professional | | $1,583.30 | $1,583.30 | $1,765.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,460.50 / $1,460.50 / $2,190.75
| Facility | | $1,460.50 | $1,460.50 | $2,190.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,241.43 / $1,241.43 / $1,825.63
| Professional | | $1,241.43 | $1,241.43 | $1,825.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,808.17 / $2,324.79 / $2,789.75
| Professional | | $1,808.17 | $2,324.79 | $2,789.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $907.51 / $1,288.68 / $2,043.49
| Professional | | $907.51 | $1,288.68 | $2,043.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,701.44 / $1,701.44 / $2,195.64
| Professional | | $1,701.44 | $1,701.44 | $2,195.64 |