- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $932.23 / $1,246.03 / $4,440.52
| Professional | | $932.23 | $1,246.03 | $4,440.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,383.91 / $1,383.91 / $1,383.91
| Facility | | $1,383.91 | $1,383.91 | $1,383.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $694.26 / $1,363.04 / $1,383.91
| Professional | | $694.26 | $1,363.04 | $1,383.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $679.24 / $933.96 / $1,383.91
| Facility | | $679.24 | $933.96 | $1,383.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $848.86 / $1,363.04 / $1,836.80
| Professional | | $848.86 | $1,363.04 | $1,836.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,112.69 / $1,348.47 / $1,536.47
| Professional | | $1,112.69 | $1,348.47 | $1,536.47 |