- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $935.26 / $988.71 / $1,095.58
| Professional | | $935.26 | $988.71 | $1,095.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,416.29 / $1,573.65 / $1,643.39
| Facility | | $1,416.29 | $1,573.65 | $1,643.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,770.32 / $1,770.32 / $1,770.32
| Professional | | $1,770.32 | $1,770.32 | $1,770.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,603.31 / $1,603.31 / $1,603.31
| Facility | | $1,603.31 | $1,603.31 | $1,603.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $561.16 / $801.65 / $2,137.73
| Professional | | $561.16 | $801.65 | $2,137.73 |