- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $710.09 / $822.67 / $4,348.68
| Professional | | $710.09 | $822.67 | $4,348.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,296.61 / $1,296.61 / $1,296.61
| Facility | | $1,296.61 | $1,296.61 | $1,296.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $808.76 / $1,155.83 / $2,298.39
| Professional | | $808.76 | $1,155.83 | $2,298.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $795.15 / $1,226.45 / $1,533.18
| Facility | | $795.15 | $1,226.45 | $1,533.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $852.77 / $1,311.87 / $2,186.05
| Professional | | $852.77 | $1,311.87 | $2,186.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,160.32 / $1,397.12 / $1,775.60
| Professional | | $1,160.32 | $1,397.12 | $1,775.60 |