- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $978.90 / $1,062.21 / $1,128.71
| Professional | | $978.90 | $1,062.21 | $1,128.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,486.28 / $1,486.28 / $1,486.28
| Facility | | $1,486.28 | $1,486.28 | $1,486.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,084.98 / $1,084.98 / $1,486.28
| Professional | | $1,084.98 | $1,084.98 | $1,486.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,428.89 / $1,428.89 / $1,428.89
| Facility | | $1,428.89 | $1,428.89 | $1,428.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.44 / $1,191.98 / $1,787.52
| Professional | | $1,071.44 | $1,191.98 | $1,787.52 |