- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $846.37 / $923.02 / $4,210.93
| Professional | | $846.37 | $923.02 | $4,210.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,266.13 / $1,266.13 / $1,266.13
| Facility | | $1,266.13 | $1,266.13 | $1,266.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,141.28 / $1,266.13 / $1,266.13
| Professional | | $1,141.28 | $1,266.13 | $1,266.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,266.13 / $1,266.13 / $1,266.13
| Facility | | $1,266.13 | $1,266.13 | $1,266.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $784.49 / $1,141.28 / $1,697.50
| Professional | | $784.49 | $1,141.28 | $1,697.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,251.65 / $1,444.21 / $2,228.31
| Professional | | $1,251.65 | $1,444.21 | $2,228.31 |