- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,007.44 / $1,007.44 / $1,052.88
| Professional | | $1,007.44 | $1,007.44 | $1,052.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $652.13 / $841.57 / $1,239.01
| Professional | | $652.13 | $841.57 | $1,239.01 |
- 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
- $802.87 / $1,174.67 / $1,405.99
| Professional | | $802.87 | $1,174.67 | $1,405.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $803.38 / $929.51 / $1,425.92
| Professional | | $803.38 | $929.51 | $1,425.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,007.44 / $1,007.44 / $1,007.44
| Professional | | $1,007.44 | $1,007.44 | $1,007.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $631.91 / $916.79 / $1,193.54
| Professional | | $631.91 | $916.79 | $1,193.54 |