- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $999.04 / $1,322.54 / $1,352.20
| Professional | | $999.04 | $1,322.54 | $1,352.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.25 / $812.25 / $1,061.33
| Professional | | $812.25 | $812.25 | $1,061.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,042.44 / $1,042.44 / $1,042.44
| Facility | | $1,042.44 | $1,042.44 | $1,042.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $886.07 / $886.07 / $886.07
| Professional | | $886.07 | $886.07 | $886.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $476.02 / $775.33 / $1,033.69
| Professional | | $476.02 | $775.33 | $1,033.69 |