- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.32 / $709.85 / $3,928.27
| Professional | | $645.32 | $709.85 | $3,928.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,261.92 / $1,261.92 / $1,261.92
| Facility | | $1,261.92 | $1,261.92 | $1,261.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $783.45 / $1,261.92 / $1,328.33
| Professional | | $783.45 | $1,261.92 | $1,328.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $706.09 / $860.96 / $1,762.70
| Facility | | $706.09 | $860.96 | $1,762.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $761.52 / $1,261.92 / $1,546.23
| Professional | | $761.52 | $1,261.92 | $1,546.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,117.08 / $1,256.85 / $1,392.85
| Professional | | $1,117.08 | $1,256.85 | $1,392.85 |