- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $706.44 / $849.81 / $4,182.50
| Professional | | $706.44 | $849.81 | $4,182.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,271.38 / $1,271.38 / $1,271.38
| Facility | | $1,271.38 | $1,271.38 | $1,271.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $594.00 / $1,271.38 / $1,348.49
| Professional | | $594.00 | $1,271.38 | $1,348.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $626.29 / $765.72 / $1,271.38
| Facility | | $626.29 | $765.72 | $1,271.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $740.46 / $1,271.38 / $1,658.30
| Professional | | $740.46 | $1,271.38 | $1,658.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,022.21 / $1,309.28 / $1,665.18
| Professional | | $1,022.21 | $1,309.28 | $1,665.18 |