- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $870.96 / $1,047.13
| Professional | | $794.33 | $870.96 | $1,047.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $104.71 / $104.71 / $1,230.27
| Facility | | $104.71 | $104.71 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.20 / $114.82 / $1,318.26
| Professional | | $112.20 | $114.82 | $1,318.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $371.54 / $1,230.27 / $2,511.89
| Facility | | $371.54 | $1,230.27 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.82 / $912.01 / $1,148.15
| Professional | | $128.82 | $912.01 | $1,148.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $104.71 / $794.33 / $1,258.93
| Facility | | $104.71 | $794.33 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $891.25 / $1,412.54
| Professional | | $691.83 | $891.25 | $1,412.54 |