- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $575.44 / $758.58
| Professional | | $562.34 | $575.44 | $758.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $380.19 / $891.25 / $1,862.09
| Facility | | $380.19 | $891.25 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,479.11 / $2,818.38
| Professional | | $1,122.02 | $1,479.11 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $562.34 / $575.44 / $758.58
| Facility | | $562.34 | $575.44 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $758.58 / $1,071.52
| Professional | | $758.58 | $758.58 | $1,071.52 |