- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $964.59 / $974.86 / $4,939.21
| Professional | | $964.59 | $974.86 | $4,939.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,468.03 / $1,468.03 / $1,468.03
| Facility | | $1,468.03 | $1,468.03 | $1,468.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,087.72 / $1,468.03 / $1,569.65
| Professional | | $1,087.72 | $1,468.03 | $1,569.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $725.98 / $1,751.75 / $1,796.30
| Facility | | $725.98 | $1,751.75 | $1,796.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $885.74 / $1,328.75 / $1,916.60
| Professional | | $885.74 | $1,328.75 | $1,916.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,374.44 / $1,625.41 / $2,551.15
| Professional | | $1,374.44 | $1,625.41 | $2,551.15 |