- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.03 / $426.58 / $1,905.46
| Professional | | $263.03 | $426.58 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $741.31 / $870.96 / $1,659.59
| Facility | | $741.31 | $870.96 | $1,659.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.83 / $1,230.27 / $2,187.76
| Facility | | $812.83 | $1,230.27 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $724.44 / $724.44 / $724.44
| Facility | | $724.44 | $724.44 | $724.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $1,949.84 / $1,949.84
| Professional | | $1,949.84 | $1,949.84 | $1,949.84 |