- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $819.57 / $965.60 / $5,083.97
| Professional | | $819.57 | $965.60 | $5,083.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,541.12 / $1,541.12 / $1,541.12
| Facility | | $1,541.12 | $1,541.12 | $1,541.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $918.61 / $1,541.12 / $2,788.87
| Professional | | $918.61 | $1,541.12 | $2,788.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $951.13 / $1,299.02 / $1,779.22
| Facility | | $951.13 | $1,299.02 | $1,779.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $972.66 / $1,570.15 / $2,616.42
| Professional | | $972.66 | $1,570.15 | $2,616.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,337.15 / $1,656.32 / $2,053.50
| Professional | | $1,337.15 | $1,656.32 | $2,053.50 |