- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $640.82 / $760.28 / $4,007.06
| Professional | | $640.82 | $760.28 | $4,007.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,228.79 / $1,228.79 / $1,228.79
| Facility | | $1,228.79 | $1,228.79 | $1,228.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $736.23 / $1,228.79 / $2,168.10
| Professional | | $736.23 | $1,228.79 | $2,168.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $758.19 / $1,075.57 / $1,396.56
| Facility | | $758.19 | $1,075.57 | $1,396.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $767.78 / $1,252.56 / $2,087.21
| Professional | | $767.78 | $1,252.56 | $2,087.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,063.14 / $1,294.08 / $1,632.70
| Professional | | $1,063.14 | $1,294.08 | $1,632.70 |