- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $948.27 / $1,278.30 / $1,352.62
| Professional | | $948.27 | $1,278.30 | $1,352.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,382.89 / $1,626.93 / $1,626.93
| Professional | | $1,382.89 | $1,626.93 | $1,626.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,406.76 / $1,406.76 / $1,406.76
| Facility | | $1,406.76 | $1,406.76 | $1,406.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,195.75 / $1,406.76 / $1,406.76
| Professional | | $1,195.75 | $1,406.76 | $1,406.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,011.49 / $1,366.75 / $2,277.92
| Professional | | $1,011.49 | $1,366.75 | $2,277.92 |