- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,380.38 / $1,412.54
| Professional | | $1,348.96 | $1,380.38 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $199.53 / $269.15 / $309.03
| Professional | | $199.53 | $269.15 | $309.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,445.44 / $1,445.44
| Facility | | $1,445.44 | $1,445.44 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,445.44 / $2,511.89
| Professional | | $1,445.44 | $1,445.44 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,089.30 / $2,454.71
| Professional | | $2,089.30 | $2,089.30 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,412.54 / $1,412.54
| Professional | | $1,348.96 | $1,412.54 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $1,659.59 / $2,454.71
| Professional | | $1,659.59 | $1,659.59 | $2,454.71 |