- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $912.01 / $1,096.48
| Professional | | $912.01 | $912.01 | $1,096.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $12,589.25 / $25,703.96
| Facility | | $1,698.24 | $12,589.25 | $25,703.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $1,737.80 / $1,737.80
| Professional | | $1,737.80 | $1,737.80 | $1,737.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,202.26 / $1,202.26
| Facility | | $1,202.26 | $1,202.26 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $851.14 / $954.99
| Professional | | $741.31 | $851.14 | $954.99 |