- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $772.05 / $957.14 / $3,635.95
| Professional | | $772.05 | $957.14 | $3,635.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,121.01 / $1,121.01 / $1,121.01
| Facility | | $1,121.01 | $1,121.01 | $1,121.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $716.04 / $1,121.01 / $1,230.34
| Professional | | $716.04 | $1,121.01 | $1,230.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $552.26 / $759.35 / $1,246.43
| Facility | | $552.26 | $759.35 | $1,246.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $683.56 / $1,121.01 / $1,523.90
| Professional | | $683.56 | $1,121.01 | $1,523.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $901.31 / $1,201.19 / $1,431.68
| Professional | | $901.31 | $1,201.19 | $1,431.68 |