- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,201.75 / $1,422.03 / $1,620.45
| Professional | | $1,201.75 | $1,422.03 | $1,620.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,618.64 / $1,759.39 / $1,759.39
| Professional | | $1,618.64 | $1,759.39 | $1,759.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,217.05 / $1,217.05 / $1,629.32
| Facility | | $1,217.05 | $1,217.05 | $1,629.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,034.49 / $1,217.05 / $2,685.94
| Professional | | $1,034.49 | $1,217.05 | $2,685.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $661.41 / $1,121.06 / $1,653.52
| Professional | | $661.41 | $1,121.06 | $1,653.52 |