- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $622.14 / $712.71 / $3,727.28
| Professional | | $622.14 | $712.71 | $3,727.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,133.61 / $1,133.61 / $1,133.61
| Facility | | $1,133.61 | $1,133.61 | $1,133.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $788.39 / $1,133.61 / $1,180.88
| Professional | | $788.39 | $1,133.61 | $1,180.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $555.22 / $1,229.80 / $1,298.52
| Facility | | $555.22 | $1,229.80 | $1,298.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $690.03 / $1,035.14 / $1,493.10
| Professional | | $690.03 | $1,035.14 | $1,493.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $968.67 / $1,216.00 / $1,987.83
| Professional | | $968.67 | $1,216.00 | $1,987.83 |