- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $722.66 / $754.25 / $776.76
| Professional | | $722.66 | $754.25 | $776.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $788.01 / $1,072.35 / $1,295.16
| Professional | | $788.01 | $1,072.35 | $1,295.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,351.52 / $1,351.52 / $1,351.52
| Facility | | $1,351.52 | $1,351.52 | $1,351.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $894.40 / $1,234.50 / $1,543.13
| Professional | | $894.40 | $1,234.50 | $1,543.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $433.14 / $704.39 / $1,164.19
| Professional | | $433.14 | $704.39 | $1,164.19 |