- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $954.99 / $2,754.23
| Professional | | $776.25 | $954.99 | $2,754.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,513.56 / $1,513.56
| Facility | | $1,513.56 | $1,513.56 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,096.48 / $1,096.48
| Professional | | $1,096.48 | $1,096.48 | $1,096.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1.82 / $1,479.11 / $1,621.81
| Facility | | $1.82 | $1,479.11 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,230.27 / $1,737.80
| Professional | | $1,047.13 | $1,230.27 | $1,737.80 |