- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.14 / $1,498.77 / $4,668.64
| Professional | | $707.14 | $1,498.77 | $4,668.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,164.65 / $1,164.65 / $1,164.65
| Facility | | $1,164.65 | $1,164.65 | $1,164.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $878.18 / $1,243.73 / $1,466.06
| Professional | | $878.18 | $1,243.73 | $1,466.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $650.04 / $865.61 / $1,642.41
| Facility | | $650.04 | $865.61 | $1,642.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $828.45 / $1,188.36 / $1,660.66
| Professional | | $828.45 | $1,188.36 | $1,660.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,285.85 / $1,467.40 / $1,603.52
| Professional | | $1,285.85 | $1,467.40 | $1,603.52 |