- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,156.72 / $1,378.22 / $2,744.15
| Professional | | $1,156.72 | $1,378.22 | $2,744.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,507.00 / $1,507.00 / $1,921.35
| Professional | | $1,507.00 | $1,507.00 | $1,921.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,711.28 / $1,711.28 / $1,711.28
| Facility | | $1,711.28 | $1,711.28 | $1,711.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,249.23 / $1,249.23 / $1,711.28
| Professional | | $1,249.23 | $1,249.23 | $1,711.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,967.46 / $2,810.65 / $4,047.34
| Professional | | $1,967.46 | $2,810.65 | $4,047.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,266.06 / $1,408.49 / $2,223.50
| Professional | | $1,266.06 | $1,408.49 | $2,223.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,657.18 / $1,657.18 / $1,967.46
| Professional | | $1,657.18 | $1,657.18 | $1,967.46 |