- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $850.65 / $850.65 / $3,838.58
| Professional | | $850.65 | $850.65 | $3,838.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,109.96 / $1,109.96 / $1,109.96
| Facility | | $1,109.96 | $1,109.96 | $1,109.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $790.92 / $1,109.96 / $1,246.64
| Professional | | $790.92 | $1,109.96 | $1,246.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $548.54 / $1,314.95 / $1,378.22
| Facility | | $548.54 | $1,314.95 | $1,378.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $667.38 / $1,001.17 / $1,444.10
| Professional | | $667.38 | $1,001.17 | $1,444.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,031.73 / $1,274.40 / $2,049.80
| Professional | | $1,031.73 | $1,274.40 | $2,049.80 |