- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $460.92 / $599.40 / $4,012.73
| Professional | | $460.92 | $599.40 | $4,012.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $977.46 / $977.46 / $977.46
| Facility | | $977.46 | $977.46 | $977.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $805.65 / $977.46 / $1,196.72
| Professional | | $805.65 | $977.46 | $1,196.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $591.17 / $1,192.09 / $1,279.55
| Facility | | $591.17 | $1,192.09 | $1,279.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $639.30 / $977.46 / $1,368.63
| Professional | | $639.30 | $977.46 | $1,368.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,022.72 / $1,262.08 / $2,100.67
| Professional | | $1,022.72 | $1,262.08 | $2,100.67 |