- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $791.25 / $982.30 / $4,110.49
| Professional | | $791.25 | $982.30 | $4,110.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,224.06 / $1,224.06 / $1,224.06
| Facility | | $1,224.06 | $1,224.06 | $1,224.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $906.20 / $1,224.06 / $1,301.34
| Professional | | $906.20 | $1,224.06 | $1,301.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $605.86 / $1,436.50 / $1,476.89
| Facility | | $605.86 | $1,436.50 | $1,476.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $737.90 / $1,106.97 / $1,596.70
| Professional | | $737.90 | $1,106.97 | $1,596.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,127.09 / $1,352.40 / $2,128.41
| Professional | | $1,127.09 | $1,352.40 | $2,128.41 |