- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $728.36 / $791.22 / $1,128.61
| Professional | | $728.36 | $791.22 | $1,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,153.76 / $1,357.37 / $2,335.94
| Professional | | $1,153.76 | $1,357.37 | $2,335.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,460.50 / $1,460.50 / $1,916.91
| Facility | | $1,460.50 | $1,460.50 | $1,916.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,241.43 / $1,460.50 / $1,916.91
| Professional | | $1,241.43 | $1,460.50 | $1,916.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $843.97 / $1,475.18 / $2,147.80
| Professional | | $843.97 | $1,475.18 | $2,147.80 |