- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $785.65 / $988.46 / $1,066.47
| Professional | | $785.65 | $988.46 | $1,066.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,542.31 / $3,433.72 / $4,065.12
| Facility | | $2,542.31 | $3,433.72 | $4,065.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $803.22 / $944.97 / $1,580.39
| Professional | | $803.22 | $944.97 | $1,580.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,191.78 / $1,191.78 / $1,191.78
| Facility | | $1,191.78 | $1,191.78 | $1,191.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.00 / $1,191.78 / $1,191.78
| Professional | | $870.00 | $1,191.78 | $1,191.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $695.88 / $897.07 / $1,495.12
| Professional | | $695.88 | $897.07 | $1,495.12 |