- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $509.47 / $673.91 / $785.56
| Professional | | $509.47 | $673.91 | $785.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $927.49 / $1,446.37 / $1,607.08
| Facility | | $927.49 | $1,446.37 | $1,607.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $786.31 / $956.62 / $1,517.31
| Professional | | $786.31 | $956.62 | $1,517.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,439.58 / $2,138.90 / $3,760.05
| Facility | | $1,439.58 | $2,138.90 | $3,760.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $996.48 / $1,541.96 / $2,179.07
| Professional | | $996.48 | $1,541.96 | $2,179.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $561.00 / $961.72 / $1,282.29
| Professional | | $561.00 | $961.72 | $1,282.29 |