- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $915.18 / $1,233.69 / $1,305.54
| Professional | | $915.18 | $1,233.69 | $1,305.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,334.64 / $1,570.16 / $1,570.16
| Professional | | $1,334.64 | $1,570.16 | $1,570.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,219.64 / $1,219.64 / $1,219.64
| Facility | | $1,219.64 | $1,219.64 | $1,219.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,036.69 / $1,219.64 / $1,219.64
| Professional | | $1,036.69 | $1,219.64 | $1,219.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $976.19 / $1,232.85 / $2,198.79
| Professional | | $976.19 | $1,232.85 | $2,198.79 |