- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $838.10 / $1,449.38 / $4,806.35
| Professional | | $838.10 | $1,449.38 | $4,806.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,234.05 / $1,234.05 / $1,234.05
| Facility | | $1,234.05 | $1,234.05 | $1,234.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $560.26 / $1,048.94 / $1,359.56
| Professional | | $560.26 | $1,048.94 | $1,359.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $544.83 / $748.14 / $1,234.05
| Facility | | $544.83 | $748.14 | $1,234.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $777.69 / $1,284.03 / $1,863.98
| Professional | | $777.69 | $1,284.03 | $1,863.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $974.97 / $1,386.55 / $1,597.81
| Professional | | $974.97 | $1,386.55 | $1,597.81 |