- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $800.08 / $851.41 / $4,313.33
| Professional | | $800.08 | $851.41 | $4,313.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,285.58 / $1,285.58 / $1,285.58
| Facility | | $1,285.58 | $1,285.58 | $1,285.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $972.70 / $1,285.58 / $1,365.95
| Professional | | $972.70 | $1,285.58 | $1,365.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $635.84 / $1,541.15 / $1,604.65
| Facility | | $635.84 | $1,541.15 | $1,604.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $774.14 / $1,161.32 / $1,675.10
| Professional | | $774.14 | $1,161.32 | $1,675.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,209.22 / $1,394.76 / $2,233.88
| Professional | | $1,209.22 | $1,394.76 | $2,233.88 |