- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $746.10 / $757.04 / $3,772.70
| Professional | | $746.10 | $757.04 | $3,772.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,126.26 / $1,126.26 / $1,126.26
| Facility | | $1,126.26 | $1,126.26 | $1,126.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $835.71 / $1,126.26 / $1,193.09
| Professional | | $835.71 | $1,126.26 | $1,193.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $557.04 / $1,344.20 / $1,400.99
| Facility | | $557.04 | $1,344.20 | $1,400.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $678.38 / $1,017.67 / $1,467.90
| Professional | | $678.38 | $1,017.67 | $1,467.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,054.68 / $1,280.92 / $1,957.29
| Professional | | $1,054.68 | $1,280.92 | $1,957.29 |