- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $671.30 / $889.55 / $3,310.41
| Professional | | $671.30 | $889.55 | $3,310.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,012.17 / $1,012.17 / $1,012.17
| Facility | | $1,012.17 | $1,012.17 | $1,012.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $483.72 / $1,012.17 / $1,062.15
| Professional | | $483.72 | $1,012.17 | $1,062.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $502.34 / $627.92 / $1,012.17
| Facility | | $502.34 | $627.92 | $1,012.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $592.50 / $1,011.54 / $1,313.20
| Professional | | $592.50 | $1,011.54 | $1,313.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $854.93 / $1,018.64 / $1,164.16
| Professional | | $854.93 | $1,018.64 | $1,164.16 |