- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $708.33 / $968.19 / $3,491.98
| Professional | | $708.33 | $968.19 | $3,491.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,064.22 / $1,064.22 / $1,064.22
| Facility | | $1,064.22 | $1,064.22 | $1,064.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $646.69 / $1,064.22 / $1,257.11
| Professional | | $646.69 | $1,064.22 | $1,257.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $524.74 / $721.51 / $1,064.22
| Facility | | $524.74 | $721.51 | $1,064.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $649.91 / $1,064.22 / $1,454.60
| Professional | | $649.91 | $1,064.22 | $1,454.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $955.74 / $1,105.66 / $1,252.23
| Professional | | $955.74 | $1,105.66 | $1,252.23 |