- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $817.68 / $1,014.48 / $1,074.98
| Professional | | $817.68 | $1,014.48 | $1,074.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,097.49 / $1,291.16 / $1,291.16
| Professional | | $1,097.49 | $1,291.16 | $1,291.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,639.62 / $1,639.62 / $1,639.62
| Facility | | $1,639.62 | $1,639.62 | $1,639.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,393.68 / $1,639.62 / $1,639.62
| Professional | | $1,393.68 | $1,639.62 | $1,639.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $872.19 / $1,101.25 / $1,964.07
| Professional | | $872.19 | $1,101.25 | $1,964.07 |