- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $651.28 / $814.19 / $1,540.11
| Professional | | $651.28 | $814.19 | $1,540.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,565.83 / $1,565.83 / $1,565.83
| Facility | | $1,565.83 | $1,565.83 | $1,565.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $839.79 / $1,109.21 / $2,413.57
| Professional | | $839.79 | $1,109.21 | $2,413.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $722.39 / $1,090.61 / $1,541.26
| Facility | | $722.39 | $1,090.61 | $1,541.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,045.89 / $1,846.61 / $2,681.12
| Professional | | $1,045.89 | $1,846.61 | $2,681.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,084.29 / $1,334.58 / $1,665.18
| Professional | | $1,084.29 | $1,334.58 | $1,665.18 |