- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $624.08 / $3,605.72 / $4,741.06
| Professional | | $624.08 | $3,605.72 | $4,741.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.92 / $1,047.92 / $1,047.92
| Facility | | $1,047.92 | $1,047.92 | $1,047.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $888.57 / $1,065.06 / $1,403.78
| Professional | | $888.57 | $1,065.06 | $1,403.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $591.99 / $823.23 / $1,467.92
| Facility | | $591.99 | $823.23 | $1,467.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $806.49 / $1,142.54 / $1,592.75
| Professional | | $806.49 | $1,142.54 | $1,592.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,267.76 / $1,411.20 / $1,597.18
| Professional | | $1,267.76 | $1,411.20 | $1,597.18 |