- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $627.74 / $749.61 / $3,956.41
| Professional | | $627.74 | $749.61 | $3,956.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,215.11 / $1,215.11 / $1,215.11
| Facility | | $1,215.11 | $1,215.11 | $1,215.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $731.77 / $1,215.11 / $2,162.39
| Professional | | $731.77 | $1,215.11 | $2,162.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $749.86 / $1,066.13 / $1,374.42
| Facility | | $749.86 | $1,066.13 | $1,374.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.59 / $1,234.77 / $2,057.56
| Professional | | $758.59 | $1,234.77 | $2,057.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,027.76 / $1,270.40 / $1,608.88
| Professional | | $1,027.76 | $1,270.40 | $1,608.88 |