- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $460.62 / $700.56 / $2,693.37
| Facility | | $460.62 | $700.56 | $2,693.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.30 / $460.62 / $490.39
| Professional | | $371.30 | $460.62 | $490.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $362.69 / $1,028.07 / $1,733.89
| Facility | | $362.69 | $1,028.07 | $1,733.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $357.28 / $887.20 / $1,170.08
| Professional | | $357.28 | $887.20 | $1,170.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $805.64 / $1,276.42 / $1,730.38
| Professional | | $805.64 | $1,276.42 | $1,730.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $322.26 / $420.34 / $1,229.41
| Professional | | $322.26 | $420.34 | $1,229.41 |