- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.01 / $3,860.40 / $4,224.63
| Professional | | $707.01 | $3,860.40 | $4,224.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,149.40 / $1,149.40 / $1,149.40
| Facility | | $1,149.40 | $1,149.40 | $1,149.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $800.26 / $1,145.96 / $1,255.08
| Professional | | $800.26 | $1,145.96 | $1,255.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $644.98 / $853.55 / $1,550.34
| Facility | | $644.98 | $853.55 | $1,550.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $753.93 / $1,147.25 / $1,527.68
| Professional | | $753.93 | $1,147.25 | $1,527.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,083.82 / $1,337.49 / $1,461.55
| Professional | | $1,083.82 | $1,337.49 | $1,461.55 |