- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.34 / $797.07 / $996.34
| Professional | | $630.34 | $797.07 | $996.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $527.15 / $614.50 / $1,755.72
| Facility | | $527.15 | $614.50 | $1,755.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $526.72 / $961.95 / $2,194.65
| Professional | | $526.72 | $961.95 | $2,194.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $527.15 / $904.20 / $1,214.33
| Facility | | $527.15 | $904.20 | $1,214.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $526.72 / $894.25 / $1,196.67
| Professional | | $526.72 | $894.25 | $1,196.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $438.93 / $438.93 / $783.49
| Professional | | $438.93 | $438.93 | $783.49 |