- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $715.25 / $854.06 / $4,182.75
| Professional | | $715.25 | $854.06 | $4,182.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,247.72 / $1,247.72 / $1,247.72
| Facility | | $1,247.72 | $1,247.72 | $1,247.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $757.65 / $1,247.72 / $1,359.55
| Professional | | $757.65 | $1,247.72 | $1,359.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $616.10 / $847.13 / $1,287.41
| Facility | | $616.10 | $847.13 | $1,287.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $763.78 / $1,247.72 / $1,694.00
| Professional | | $763.78 | $1,247.72 | $1,694.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,194.93 / $1,355.20 / $1,509.11
| Professional | | $1,194.93 | $1,355.20 | $1,509.11 |