- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $885.89 / $1,105.80 / $1,256.19
| Professional | | $885.89 | $1,105.80 | $1,256.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,020.40 / $1,350.53 / $1,500.59
| Professional | | $1,020.40 | $1,350.53 | $1,500.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,315.87 / $1,315.87 / $1,315.87
| Facility | | $1,315.87 | $1,315.87 | $1,315.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $924.07 / $1,247.63 / $1,808.34
| Professional | | $924.07 | $1,247.63 | $1,808.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $822.19 / $1,042.48 / $1,674.46
| Professional | | $822.19 | $1,042.48 | $1,674.46 |