- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $719.15 / $904.78 / $976.20
| Professional | | $719.15 | $904.78 | $976.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,327.10 / $3,143.08 / $3,721.04
| Facility | | $2,327.10 | $3,143.08 | $3,721.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $787.75 / $926.77 / $1,488.44
| Professional | | $787.75 | $926.77 | $1,488.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $941.33 / $941.33 / $941.33
| Facility | | $941.33 | $941.33 | $941.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $687.17 / $941.33 / $941.33
| Professional | | $687.17 | $941.33 | $941.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $636.97 / $821.14 / $1,368.56
| Professional | | $636.97 | $821.14 | $1,368.56 |