- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $677.19 / $852.21 / $919.23
| Professional | | $677.19 | $852.21 | $919.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,191.33 / $2,959.68 / $3,503.91
| Facility | | $2,191.33 | $2,959.68 | $3,503.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $860.46 / $1,012.31 / $1,401.59
| Professional | | $860.46 | $1,012.31 | $1,401.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $950.52 / $950.52 / $950.52
| Facility | | $950.52 | $950.52 | $950.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $693.88 / $950.52 / $950.52
| Professional | | $693.88 | $950.52 | $950.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $698.84 / $943.85 / $1,288.70
| Professional | | $698.84 | $943.85 | $1,288.70 |