- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $782.42 / $857.33 / $4,382.05
| Professional | | $782.42 | $857.33 | $4,382.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,336.06 / $1,336.06 / $1,336.06
| Facility | | $1,336.06 | $1,336.06 | $1,336.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $815.54 / $1,194.97 / $2,285.04
| Professional | | $815.54 | $1,194.97 | $2,285.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $823.82 / $1,215.61 / $1,668.21
| Facility | | $823.82 | $1,215.61 | $1,668.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $860.39 / $1,357.71 / $2,262.42
| Professional | | $860.39 | $1,357.71 | $2,262.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,182.50 / $1,395.35 / $1,707.04
| Professional | | $1,182.50 | $1,395.35 | $1,707.04 |