- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $678.52 / $896.50 / $3,325.44
| Professional | | $678.52 | $896.50 | $3,325.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,018.48 / $1,018.48 / $1,018.48
| Professional | | $1,018.48 | $1,018.48 | $1,018.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,018.47 / $1,018.47 / $1,018.47
| Facility | | $1,018.47 | $1,018.47 | $1,018.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $527.40 / $1,018.47 / $1,060.99
| Professional | | $527.40 | $1,018.47 | $1,060.99 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $504.65 / $693.89 / $1,018.47
| Facility | | $504.65 | $693.89 | $1,018.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $613.03 / $1,018.47 / $1,326.50
| Professional | | $613.03 | $1,018.47 | $1,326.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $790.34 / $1,043.09 / $1,199.86
| Professional | | $790.34 | $1,043.09 | $1,199.86 |