- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $939.73 / $1,040.74 / $1,348.96
| Professional | | $939.73 | $1,040.74 | $1,348.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,396.97 / $1,396.97 / $1,396.97
| Facility | | $1,396.97 | $1,396.97 | $1,396.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,396.97 / $1,396.97 / $1,396.97
| Professional | | $1,396.97 | $1,396.97 | $1,396.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,116.58 / $1,116.58 / $1,422.22
| Facility | | $1,116.58 | $1,116.58 | $1,422.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $949.10 / $1,116.58 / $1,338.37
| Professional | | $949.10 | $1,116.58 | $1,338.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $572.85 / $864.06 / $1,542.72
| Professional | | $572.85 | $864.06 | $1,542.72 |