- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,018.85 / $1,326.80 / $1,993.26
| Professional | | $1,018.85 | $1,326.80 | $1,993.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,337.00 / $1,397.13 / $1,704.24
| Professional | | $1,337.00 | $1,397.13 | $1,704.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,654.54 / $1,654.54 / $1,654.54
| Facility | | $1,654.54 | $1,654.54 | $1,654.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,207.81 / $1,207.81 / $1,654.54
| Professional | | $1,207.81 | $1,207.81 | $1,654.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,745.14 / $2,493.06 / $3,590.01
| Professional | | $1,745.14 | $2,493.06 | $3,590.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,123.00 / $1,311.48 / $1,972.26
| Professional | | $1,123.00 | $1,311.48 | $1,972.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,378.13 / $1,378.13 / $1,745.14
| Professional | | $1,378.13 | $1,378.13 | $1,745.14 |