- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $626.41 / $821.49 / $4,353.83
| Professional | | $626.41 | $821.49 | $4,353.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $455.46 / $622.46 / $1,730.75
| Facility | | $455.46 | $622.46 | $1,730.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.25 / $969.30 / $1,444.62
| Professional | | $630.25 | $969.30 | $1,444.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $455.46 / $897.26 / $1,526.20
| Facility | | $455.46 | $897.26 | $1,526.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.96 / $1,027.05 / $1,444.62
| Professional | | $724.96 | $1,027.05 | $1,444.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $872.50 / $965.40 / $1,356.33
| Professional | | $872.50 | $965.40 | $1,356.33 |