- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,445.44 / $2,754.23
| Professional | | $1,096.48 | $1,445.44 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,174.90 / $1,288.25
| Professional | | $1,071.52 | $1,174.90 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,122.02 / $1,621.81
| Professional | | $977.24 | $1,122.02 | $1,621.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,380.38 / $2,238.72
| Facility | | $1,380.38 | $1,380.38 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,071.52 / $2,238.72
| Professional | | $851.14 | $1,071.52 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,071.52 / $1,584.89
| Professional | | $912.01 | $1,071.52 | $1,584.89 |