- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $755.45 / $927.08 / $1,025.47
| Professional | | $755.45 | $927.08 | $1,025.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,444.57 / $3,301.72 / $3,908.85
| Facility | | $2,444.57 | $3,301.72 | $3,908.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $772.34 / $908.64 / $1,519.64
| Professional | | $772.34 | $908.64 | $1,519.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,260.83 / $1,260.83 / $1,260.83
| Facility | | $1,260.83 | $1,260.83 | $1,260.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $920.41 / $1,260.83 / $1,260.83
| Professional | | $920.41 | $1,260.83 | $1,260.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $779.62 / $987.42 / $1,437.63
| Professional | | $779.62 | $987.42 | $1,437.63 |