- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $794.33 / $1,513.56
| Professional | | $691.83 | $794.33 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,258.93 / $1,258.93
| Professional | | $1,258.93 | $1,258.93 | $1,258.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $831.76 / $831.76 / $2,454.71
| Facility | | $831.76 | $831.76 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $616.60 / $1,584.89
| Professional | | $616.60 | $616.60 | $1,584.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $457.09 / $794.33 / $1,819.70
| Facility | | $457.09 | $794.33 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $446.68 / $676.08 / $1,047.13
| Professional | | $446.68 | $676.08 | $1,047.13 |