- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $828.27 / $832.30 / $4,212.97
| Professional | | $828.27 | $832.30 | $4,212.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,255.60 / $1,255.60 / $1,255.60
| Facility | | $1,255.60 | $1,255.60 | $1,255.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $903.81 / $1,255.60 / $1,334.53
| Professional | | $903.81 | $1,255.60 | $1,334.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $621.37 / $1,502.80 / $1,538.24
| Facility | | $621.37 | $1,502.80 | $1,538.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $756.67 / $1,135.11 / $1,637.30
| Professional | | $756.67 | $1,135.11 | $1,637.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,179.11 / $1,385.40 / $2,181.15
| Professional | | $1,179.11 | $1,385.40 | $2,181.15 |