- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $800.59 / $1,037.72 / $1,098.02
| Professional | | $800.59 | $1,037.72 | $1,098.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.61 / $1,320.73 / $1,320.73
| Professional | | $1,122.61 | $1,320.73 | $1,320.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,450.41 / $1,450.41 / $1,450.41
| Facility | | $1,450.41 | $1,450.41 | $1,450.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,232.84 / $1,232.84 / $1,232.84
| Professional | | $1,232.84 | $1,232.84 | $1,232.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $853.96 / $1,153.91 / $1,923.19
| Professional | | $853.96 | $1,153.91 | $1,923.19 |