- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $561.74 / $846.18 / $1,057.73
| Professional | | $561.74 | $846.18 | $1,057.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $511.03 / $511.03 / $511.03
| Facility | | $511.03 | $511.03 | $511.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $511.03 / $1,807.50
| Professional | | $125.89 | $511.03 | $1,807.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $110.03 / $704.10 / $8,228.75
| Facility | | $110.03 | $704.10 | $8,228.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $514.49 / $771.02 / $1,220.21
| Professional | | $514.49 | $771.02 | $1,220.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $568.15 / $719.61 / $1,110.10
| Professional | | $568.15 | $719.61 | $1,110.10 |