- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,145.35 / $1,307.20 / $1,505.27
| Professional | | $1,145.35 | $1,307.20 | $1,505.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,228.70 / $2,310.00 / $3,112.03
| Professional | | $1,228.70 | $2,310.00 | $3,112.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,716.72 / $2,231.73 / $2,403.41
| Facility | | $1,716.72 | $2,231.73 | $2,403.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,716.72 / $1,888.39 / $2,145.90
| Professional | | $1,716.72 | $1,888.39 | $2,145.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $742.34 / $742.34 / $3,049.20
| Professional | | $742.34 | $742.34 | $3,049.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $514.37 / $806.18 / $1,096.61
| Professional | | $514.37 | $806.18 | $1,096.61 |