- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $910.34 / $982.11 / $4,607.75
| Professional | | $910.34 | $982.11 | $4,607.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,370.76 / $1,370.76 / $1,370.76
| Facility | | $1,370.76 | $1,370.76 | $1,370.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,005.54 / $1,370.76 / $1,461.40
| Professional | | $1,005.54 | $1,370.76 | $1,461.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $677.93 / $1,635.40 / $1,674.23
| Facility | | $677.93 | $1,635.40 | $1,674.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $827.19 / $1,240.91 / $1,789.90
| Professional | | $827.19 | $1,240.91 | $1,789.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,314.57 / $1,602.25 / $2,386.50
| Professional | | $1,314.57 | $1,602.25 | $2,386.50 |