- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $783.96 / $808.22 / $1,064.16
| Professional | | $783.96 | $808.22 | $1,064.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,536.81 / $3,426.28 / $4,056.32
| Facility | | $2,536.81 | $3,426.28 | $4,056.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $801.49 / $942.93 / $1,576.97
| Professional | | $801.49 | $942.93 | $1,576.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $870.50 / $870.50 / $1,037.83
| Facility | | $870.50 | $870.50 | $1,037.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $635.47 / $870.50 / $870.50
| Professional | | $635.47 | $870.50 | $870.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $809.03 / $1,010.28 / $1,491.88
| Professional | | $809.03 | $1,010.28 | $1,491.88 |