- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $918.25 / $968.76 / $1,619.39
| Professional | | $918.25 | $968.76 | $1,619.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,622.09 / $1,622.09 / $1,622.09
| Facility | | $1,622.09 | $1,622.09 | $1,622.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,346.07 / $1,622.09 / $1,768.57
| Professional | | $1,346.07 | $1,622.09 | $1,768.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $912.39 / $1,001.89 / $1,603.02
| Facility | | $912.39 | $1,001.89 | $1,603.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $983.76 / $1,475.80 / $1,989.77
| Professional | | $983.76 | $1,475.80 | $1,989.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,599.02 / $1,766.46 / $1,924.41
| Professional | | $1,599.02 | $1,766.46 | $1,924.41 |