- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $617.50 / $618.48 / $3,556.82
| Professional | | $617.50 | $618.48 | $3,556.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,088.41 / $1,088.41 / $1,088.41
| Facility | | $1,088.41 | $1,088.41 | $1,088.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $564.86 / $1,088.41 / $1,137.23
| Professional | | $564.86 | $1,088.41 | $1,137.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $540.28 / $742.89 / $1,088.41
| Facility | | $540.28 | $742.89 | $1,088.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $654.76 / $1,088.41 / $1,416.80
| Professional | | $654.76 | $1,088.41 | $1,416.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $919.78 / $1,114.76 / $1,252.47
| Professional | | $919.78 | $1,114.76 | $1,252.47 |