- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $636.41 / $745.14 / $4,046.75
| Professional | | $636.41 | $745.14 | $4,046.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,241.41 / $1,241.41 / $1,241.41
| Facility | | $1,241.41 | $1,241.41 | $1,241.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $700.76 / $1,241.41 / $2,182.59
| Professional | | $700.76 | $1,241.41 | $2,182.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $722.20 / $981.06 / $1,391.50
| Facility | | $722.20 | $981.06 | $1,391.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $772.79 / $1,266.58 / $2,110.58
| Professional | | $772.79 | $1,266.58 | $2,110.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,073.01 / $1,287.67 / $1,711.88
| Professional | | $1,073.01 | $1,287.67 | $1,711.88 |