- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,347.22 / $1,347.22 / $1,402.24
| Professional | | $1,347.22 | $1,347.22 | $1,402.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $869.52 / $1,122.68 / $1,660.86
| Professional | | $869.52 | $1,122.68 | $1,660.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,005.81 / $1,005.81 / $1,005.81
| Facility | | $1,005.81 | $1,005.81 | $1,005.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,074.74 / $1,578.45 / $1,889.27
| Professional | | $1,074.74 | $1,578.45 | $1,889.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.72 / $1,239.98 / $1,902.20
| Professional | | $1,071.72 | $1,239.98 | $1,902.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,347.22 / $1,347.22 / $1,347.22
| Professional | | $1,347.22 | $1,347.22 | $1,347.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $737.68 / $1,215.22 / $1,571.40
| Professional | | $737.68 | $1,215.22 | $1,571.40 |