- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $731.78 / $794.93 / $1,133.99
| Professional | | $731.78 | $794.93 | $1,133.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,159.26 / $1,363.84 / $1,363.84
| Professional | | $1,159.26 | $1,363.84 | $1,363.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $192.60 / $192.60 / $1,436.52
| Facility | | $192.60 | $192.60 | $1,436.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,221.04 / $1,221.04 / $1,221.04
| Professional | | $1,221.04 | $1,221.04 | $1,221.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $847.92 / $1,145.96 / $1,909.94
| Professional | | $847.92 | $1,145.96 | $1,909.94 |