- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $908.51 / $960.81 / $1,417.93
| Professional | | $908.51 | $960.81 | $1,417.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,453.84 / $1,453.84 / $1,453.84
| Facility | | $1,453.84 | $1,453.84 | $1,453.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,013.78 / $1,453.84 / $1,500.98
| Professional | | $1,013.78 | $1,453.84 | $1,500.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $712.45 / $1,599.65 / $1,687.51
| Facility | | $712.45 | $1,599.65 | $1,687.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $884.77 / $1,327.30 / $1,914.50
| Professional | | $884.77 | $1,327.30 | $1,914.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,255.10 / $1,575.03 / $2,545.61
| Professional | | $1,255.10 | $1,575.03 | $2,545.61 |