- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,522.02 / $1,683.64 / $1,700.82
| Professional | | $1,522.02 | $1,683.64 | $1,700.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $742.34 / $742.34 / $742.34
| Professional | | $742.34 | $742.34 | $742.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $930.02 / $1,438.33 / $2,009.60
| Facility | | $930.02 | $1,438.33 | $2,009.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $742.34 / $1,805.62 / $1,962.71
| Professional | | $742.34 | $1,805.62 | $1,962.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $697.34 / $771.56 / $1,106.90
| Professional | | $697.34 | $771.56 | $1,106.90 |