- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $892.06 / $1,015.51 / $1,045.83
| Professional | | $892.06 | $1,015.51 | $1,045.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,060.98 / $1,060.98 / $1,306.29
| Professional | | $1,060.98 | $1,060.98 | $1,306.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,116.58 / $1,116.58 / $1,116.58
| Facility | | $1,116.58 | $1,116.58 | $1,116.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $949.10 / $1,116.58 / $1,974.00
| Professional | | $949.10 | $1,116.58 | $1,974.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,277.15 / $1,277.15 / $1,277.15
| Professional | | $1,277.15 | $1,277.15 | $1,277.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $661.30 / $859.28 / $1,251.13
| Professional | | $661.30 | $859.28 | $1,251.13 |