- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $532.94 / $654.54 / $3,455.92
| Professional | | $532.94 | $654.54 | $3,455.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,063.69 / $1,063.69 / $1,063.69
| Facility | | $1,063.69 | $1,063.69 | $1,063.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.54 / $1,027.81 / $1,732.80
| Professional | | $602.54 | $1,027.81 | $1,732.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $656.37 / $888.71 / $1,163.17
| Facility | | $656.37 | $888.71 | $1,163.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $661.46 / $1,082.71 / $1,804.19
| Professional | | $661.46 | $1,082.71 | $1,804.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $914.14 / $1,083.52 / $1,361.50
| Professional | | $914.14 | $1,083.52 | $1,361.50 |