- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,003.80 / $1,169.10 / $1,459.78
| Professional | | $1,003.80 | $1,169.10 | $1,459.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,186.05 / $1,393.46 / $1,468.86
| Professional | | $1,186.05 | $1,393.46 | $1,468.86 |
- 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
- $1,325.18 / $1,325.18 / $1,325.18
| Professional | | $1,325.18 | $1,325.18 | $1,325.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $721.48 / $960.91 / $1,601.52
| Professional | | $721.48 | $960.91 | $1,601.52 |