- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $865.31 / $865.31 / $881.56
| Professional | | $865.31 | $865.31 | $881.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $552.15 / $714.35 / $1,087.32
| Professional | | $552.15 | $714.35 | $1,087.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,005.81 / $1,005.81 / $1,005.81
| Facility | | $1,005.81 | $1,005.81 | $1,005.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $698.93 / $1,037.15 / $1,241.39
| Professional | | $698.93 | $1,037.15 | $1,241.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $703.63 / $814.10 / $1,248.86
| Professional | | $703.63 | $814.10 | $1,248.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $865.31 / $865.31 / $865.31
| Professional | | $865.31 | $865.31 | $865.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $541.03 / $766.69 / $991.41
| Professional | | $541.03 | $766.69 | $991.41 |