- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $603.70 / $718.82 / $3,794.51
| Professional | | $603.70 | $718.82 | $3,794.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,166.22 / $1,166.22 / $1,166.22
| Facility | | $1,166.22 | $1,166.22 | $1,166.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $685.30 / $1,166.22 / $1,967.53
| Professional | | $685.30 | $1,166.22 | $1,967.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $720.21 / $989.10 / $1,320.03
| Facility | | $720.21 | $989.10 | $1,320.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $725.47 / $1,188.40 / $1,980.29
| Professional | | $725.47 | $1,188.40 | $1,980.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,004.38 / $1,223.68 / $1,752.33
| Professional | | $1,004.38 | $1,223.68 | $1,752.33 |