- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $946.97 / $1,459.78 / $1,574.54
| Professional | | $946.97 | $1,459.78 | $1,574.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,697.60 / $1,697.60 / $1,697.60
| Professional | | $1,697.60 | $1,697.60 | $1,697.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,217.05 / $1,217.05 / $1,629.32
| Facility | | $1,217.05 | $1,217.05 | $1,629.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,034.49 / $1,455.57 / $2,685.94
| Professional | | $1,034.49 | $1,455.57 | $2,685.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $640.61 / $992.11 / $1,715.52
| Professional | | $640.61 | $992.11 | $1,715.52 |