- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $500.70 / $652.17 / $3,449.10
| Professional | | $500.70 | $652.17 | $3,449.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,062.64 / $1,062.64 / $1,062.64
| Facility | | $1,062.64 | $1,062.64 | $1,062.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $578.98 / $963.21 / $1,641.64
| Professional | | $578.98 | $963.21 | $1,641.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $658.51 / $857.22 / $1,111.94
| Facility | | $658.51 | $857.22 | $1,111.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $651.21 / $1,085.41 / $1,808.68
| Professional | | $651.21 | $1,085.41 | $1,808.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $901.95 / $1,057.64 / $1,441.92
| Professional | | $901.95 | $1,057.64 | $1,441.92 |