- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $944.58 / $1,007.17 / $1,096.99
| Professional | | $944.58 | $1,007.17 | $1,096.99 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,186.73 / $1,186.73 / $1,186.73
| Facility | | $1,186.73 | $1,186.73 | $1,186.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,008.72 / $1,008.72 / $1,199.04
| Professional | | $1,008.72 | $1,008.72 | $1,199.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,094.83 / $1,094.83 / $1,186.73
| Facility | | $1,094.83 | $1,094.83 | $1,186.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,008.72 / $1,068.06 / $1,244.83
| Professional | | $1,008.72 | $1,068.06 | $1,244.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,264.08 / $1,593.84 / $1,758.71
| Professional | | $1,264.08 | $1,593.84 | $1,758.71 |