- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $601.65 / $758.77 / $816.69
| Professional | | $601.65 | $758.77 | $816.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,946.86 / $2,629.50 / $3,113.03
| Facility | | $1,946.86 | $2,629.50 | $3,113.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $764.48 / $899.39 / $1,245.22
| Professional | | $764.48 | $899.39 | $1,245.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,014.49 / $1,014.49 / $1,014.49
| Facility | | $1,014.49 | $1,014.49 | $1,014.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $740.58 / $1,014.49 / $1,014.49
| Professional | | $740.58 | $1,014.49 | $1,014.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $534.16 / $686.96 / $1,144.94
| Professional | | $534.16 | $686.96 | $1,144.94 |