- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $765.09 / $890.78 / $1,038.55
| Professional | | $765.09 | $890.78 | $1,038.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,475.77 / $3,343.84 / $3,958.72
| Facility | | $2,475.77 | $3,343.84 | $3,958.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $782.20 / $920.23 / $1,539.03
| Professional | | $782.20 | $920.23 | $1,539.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $926.75 / $926.75 / $926.75
| Facility | | $926.75 | $926.75 | $926.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $787.74 / $787.74 / $787.74
| Professional | | $787.74 | $787.74 | $787.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $684.01 / $936.02 / $1,455.99
| Professional | | $684.01 | $936.02 | $1,455.99 |