- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $731.01 / $790.07 / $992.29
| Professional | | $731.01 | $790.07 | $992.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,365.48 / $3,194.90 / $3,782.39
| Facility | | $2,365.48 | $3,194.90 | $3,782.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $800.74 / $942.05 / $1,512.98
| Professional | | $800.74 | $942.05 | $1,512.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $830.86 / $830.86 / $967.74
| Facility | | $830.86 | $830.86 | $967.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $606.53 / $830.86 / $830.86
| Professional | | $606.53 | $830.86 | $830.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $595.89 / $834.68 / $1,391.13
| Professional | | $595.89 | $834.68 | $1,391.13 |