- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.38 / $977.24 / $1,230.27
| Professional | | $407.38 | $977.24 | $1,230.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $446.68 / $575.44 / $645.65
| Facility | | $446.68 | $575.44 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $281.84 / $371.54 / $660.69
| Professional | | $281.84 | $371.54 | $660.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $1,380.38 / $1,412.54
| Facility | | $794.33 | $1,380.38 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.00 / $676.08 / $1,737.80
| Professional | | $302.00 | $676.08 | $1,737.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $602.56 / $602.56 / $602.56
| Facility | | $602.56 | $602.56 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.93 / $302.00 / $724.44
| Professional | | $208.93 | $302.00 | $724.44 |