- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $634.51 / $708.54 / $3,726.98
| Professional | | $634.51 | $708.54 | $3,726.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,237.73 / $1,237.73 / $1,237.73
| Facility | | $1,237.73 | $1,237.73 | $1,237.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $723.05 / $1,212.26 / $2,061.23
| Professional | | $723.05 | $1,212.26 | $2,061.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $763.75 / $1,004.49 / $1,376.95
| Facility | | $763.75 | $1,004.49 | $1,376.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.48 / $1,237.73 / $1,984.90
| Professional | | $724.48 | $1,237.73 | $1,984.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,022.55 / $1,223.66 / $1,783.65
| Professional | | $1,022.55 | $1,223.66 | $1,783.65 |