- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $696.79 / $945.84 / $1,052.42
| Professional | | $696.79 | $945.84 | $1,052.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,254.75 / $3,045.35 / $3,605.33
| Facility | | $2,254.75 | $3,045.35 | $3,605.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $838.08 / $838.08 / $1,401.64
| Professional | | $838.08 | $838.08 | $1,401.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $922.43 / $1,020.64 / $1,020.64
| Facility | | $922.43 | $1,020.64 | $1,020.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $745.07 / $1,020.64 / $1,020.64
| Professional | | $745.07 | $1,020.64 | $1,020.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $748.90 / $910.75 / $1,326.01
| Professional | | $748.90 | $910.75 | $1,326.01 |