- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $718.10 / $948.03 / $3,522.20
| Professional | | $718.10 | $948.03 | $3,522.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,078.42 / $1,078.42 / $1,078.42
| Facility | | $1,078.42 | $1,078.42 | $1,078.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $551.75 / $1,078.42 / $1,125.01
| Professional | | $551.75 | $1,078.42 | $1,125.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $534.37 / $734.76 / $1,078.42
| Facility | | $534.37 | $734.76 | $1,078.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $648.94 / $1,078.42 / $1,404.20
| Professional | | $648.94 | $1,078.42 | $1,404.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $861.78 / $1,065.34 / $1,227.68
| Professional | | $861.78 | $1,065.34 | $1,227.68 |