- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,010.30 / $1,243.53 / $2,250.09
| Professional | | $1,010.30 | $1,243.53 | $2,250.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,300.00 / $1,300.00 / $1,657.89
| Professional | | $1,300.00 | $1,300.00 | $1,657.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,769.38 / $1,769.38 / $1,769.38
| Facility | | $1,769.38 | $1,769.38 | $1,769.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,291.65 / $1,291.65 / $1,769.38
| Professional | | $1,291.65 | $1,291.65 | $1,769.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,697.68 / $2,425.26 / $3,492.37
| Professional | | $1,697.68 | $2,425.26 | $3,492.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,092.46 / $1,270.43 / $1,918.63
| Professional | | $1,092.46 | $1,270.43 | $1,918.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,467.54 / $1,467.54 / $1,697.68
| Professional | | $1,467.54 | $1,467.54 | $1,697.68 |