- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,291.29 / $1,332.36 / $1,332.36
| Professional | | $1,291.29 | $1,332.36 | $1,332.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $886.94 / $1,053.01 / $1,765.13
| Professional | | $886.94 | $1,053.01 | $1,765.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $814.23 / $814.23 / $814.23
| Facility | | $814.23 | $814.23 | $814.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,118.60 / $1,639.54 / $2,048.92
| Professional | | $1,118.60 | $1,639.54 | $2,048.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,130.25 / $1,307.70 / $2,006.08
| Professional | | $1,130.25 | $1,307.70 | $2,006.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,332.36 / $1,332.36 / $1,332.36
| Professional | | $1,332.36 | $1,332.36 | $1,332.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $828.91 / $1,117.96 / $1,445.64
| Professional | | $828.91 | $1,117.96 | $1,445.64 |