- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $967.98 / $1,304.88 / $1,380.76
| Professional | | $967.98 | $1,304.88 | $1,380.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,660.76 / $1,660.76 / $2,857.79
| Professional | | $1,660.76 | $1,660.76 | $2,857.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,786.79 / $1,786.79 / $1,786.79
| Facility | | $1,786.79 | $1,786.79 | $1,786.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,518.77 / $1,786.79 / $1,786.79
| Professional | | $1,518.77 | $1,786.79 | $1,786.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,032.52 / $1,804.75 / $2,627.63
| Professional | | $1,032.52 | $1,804.75 | $2,627.63 |