- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $800.25 / $800.25 / $1,000.31
| Professional | | $800.25 | $800.25 | $1,000.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1.00 / $1,168.16 / $1,854.71
| Facility | | $1.00 | $1,168.16 | $1,854.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $889.25 / $889.25 / $1,548.54
| Professional | | $889.25 | $889.25 | $1,548.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $889.98 / $1,089.17 / $1,596.10
| Facility | | $889.98 | $1,089.17 | $1,596.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $861.44 / $1,089.17 / $1,596.10
| Professional | | $861.44 | $1,089.17 | $1,596.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $889.25 / $889.25 / $915.93
| Professional | | $889.25 | $889.25 | $915.93 |