- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.94 / $690.97 / $3,060.86
| Professional | | $575.94 | $690.97 | $3,060.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $836.02 / $836.02 / $836.02
| Facility | | $836.02 | $836.02 | $836.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $526.37 / $836.02 / $1,290.81
| Professional | | $526.37 | $836.02 | $1,290.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $418.02 / $621.82 / $1,063.89
| Facility | | $418.02 | $621.82 | $1,063.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $597.47 / $911.39 / $1,336.50
| Professional | | $597.47 | $911.39 | $1,336.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $985.31 / $1,146.96 / $1,345.02
| Professional | | $985.31 | $1,146.96 | $1,345.02 |