- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $767.71 / $1,012.55 / $3,766.82
| Professional | | $767.71 | $1,012.55 | $3,766.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,152.03 / $1,152.03 / $1,152.03
| Facility | | $1,152.03 | $1,152.03 | $1,152.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $564.15 / $1,138.73 / $1,152.03
| Professional | | $564.15 | $1,138.73 | $1,152.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $570.50 / $784.44 / $1,152.03
| Facility | | $570.50 | $784.44 | $1,152.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $693.26 / $1,138.73 / $1,500.10
| Professional | | $693.26 | $1,138.73 | $1,500.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $974.78 / $1,197.70 / $1,327.36
| Professional | | $974.78 | $1,197.70 | $1,327.36 |