- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $933.25 / $1,047.13
| Professional | | $660.69 | $933.25 | $1,047.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,258.93 / $1,258.93
| Facility | | $1,258.93 | $1,258.93 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $912.01 / $1,258.93
| Professional | | $912.01 | $912.01 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,621.81 / $2,041.74
| Professional | | $1,348.96 | $1,621.81 | $2,041.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,023.29 / $1,230.27
| Facility | | $1,023.29 | $1,023.29 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $1,288.25 / $3,630.78
| Professional | | $602.56 | $1,288.25 | $3,630.78 |