- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $584.09 / $717.32 / $3,848.20
| Professional | | $584.09 | $717.32 | $3,848.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,176.21 / $1,176.21 / $1,176.21
| Facility | | $1,176.21 | $1,176.21 | $1,176.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $712.08 / $1,053.30 / $1,949.13
| Professional | | $712.08 | $1,053.30 | $1,949.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $683.59 / $984.38 / $1,384.54
| Facility | | $683.59 | $984.38 | $1,384.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $757.15 / $1,194.33 / $1,990.18
| Professional | | $757.15 | $1,194.33 | $1,990.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $988.38 / $1,221.29 / $1,494.10
| Professional | | $988.38 | $1,221.29 | $1,494.10 |