- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $556.94 / $607.08 / $1,083.26
| Professional | | $556.94 | $607.08 | $1,083.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,067.90 / $1,067.90 / $1,067.90
| Facility | | $1,067.90 | $1,067.90 | $1,067.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $694.97 / $1,067.90 / $1,118.59
| Professional | | $694.97 | $1,067.90 | $1,118.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $594.64 / $726.84 / $1,506.53
| Facility | | $594.64 | $726.84 | $1,506.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $640.21 / $1,067.08 / $1,301.48
| Professional | | $640.21 | $1,067.08 | $1,301.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,007.46 / $1,123.96 / $1,207.39
| Professional | | $1,007.46 | $1,123.96 | $1,207.39 |