- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,412.54 / $1,698.24
| Professional | | $1,230.27 | $1,412.54 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,548.82 / $1,737.80
| Professional | | $1,412.54 | $1,548.82 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,238.72 / $2,951.21
| Professional | | $1,949.84 | $2,238.72 | $2,951.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $741.31 / $741.31 / $1,479.11
| Facility | | $741.31 | $741.31 | $1,479.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $794.33 / $1,548.82
| Professional | | $741.31 | $794.33 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $977.24 / $977.24
| Professional | | $977.24 | $977.24 | $977.24 |