- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $530.74 / $853.01 / $984.24
| Professional | | $530.74 | $853.01 | $984.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,414.21 / $1,414.21 / $1,414.21
| Professional | | $1,414.21 | $1,414.21 | $1,414.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,162.20 / $1,162.20 / $1,433.06
| Facility | | $1,162.20 | $1,162.20 | $1,433.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $848.41 / $996.47 / $1,238.96
| Professional | | $848.41 | $996.47 | $1,238.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,162.20 / $1,162.20 / $1,433.06
| Facility | | $1,162.20 | $1,162.20 | $1,433.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $848.41 / $1,162.20 / $1,433.06
| Professional | | $848.41 | $1,162.20 | $1,433.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $581.38 / $1,035.46 / $2,020.77
| Professional | | $581.38 | $1,035.46 | $2,020.77 |