- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,156.49 / $1,321.54 / $2,154.78
| Professional | | $1,156.49 | $1,321.54 | $2,154.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.10 / $1,510.34 / $1,842.34
| Professional | | $1,445.10 | $1,510.34 | $1,842.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,786.24 / $1,786.24 / $1,786.24
| Facility | | $1,786.24 | $1,786.24 | $1,786.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,303.96 / $1,303.96 / $1,786.24
| Professional | | $1,303.96 | $1,303.96 | $1,786.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,886.56 / $2,695.08 / $3,880.92
| Professional | | $1,886.56 | $2,695.08 | $3,880.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,214.00 / $1,385.01 / $2,132.08
| Professional | | $1,214.00 | $1,385.01 | $2,132.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,492.65 / $1,492.65 / $1,886.56
| Professional | | $1,492.65 | $1,492.65 | $1,886.56 |