- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $480.48 / $661.92 / $3,507.56
| Professional | | $480.48 | $661.92 | $3,507.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,052.65 / $1,052.65 / $1,052.65
| Facility | | $1,052.65 | $1,052.65 | $1,052.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $618.20 / $952.13 / $1,763.55
| Professional | | $618.20 | $952.13 | $1,763.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $617.42 / $1,034.99 / $1,159.36
| Facility | | $617.42 | $1,034.99 | $1,159.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $656.73 / $1,077.85 / $1,796.10
| Professional | | $656.73 | $1,077.85 | $1,796.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $884.54 / $1,070.30 / $1,618.53
| Professional | | $884.54 | $1,070.30 | $1,618.53 |