- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $651.48 / $1,117.38 / $1,396.73
| Professional | | $651.48 | $1,117.38 | $1,396.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,075.01 / $2,075.01 / $2,075.01
| Facility | | $2,075.01 | $2,075.01 | $2,075.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.88 / $1,743.98 / $3,079.69
| Professional | | $169.88 | $1,743.98 | $3,079.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $675.54 / $1,482.07 / $11,227.13
| Facility | | $675.54 | $1,482.07 | $11,227.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $709.32 / $1,112.66 / $1,655.95
| Professional | | $709.32 | $1,112.66 | $1,655.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $881.50 / $1,103.39 / $1,639.32
| Professional | | $881.50 | $1,103.39 | $1,639.32 |