- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $870.96 / $1,096.48
| Professional | | $645.65 | $870.96 | $1,096.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $912.01 / $912.01 / $1,071.52
| Facility | | $912.01 | $912.01 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $660.69 / $977.24
| Professional | | $660.69 | $660.69 | $977.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,445.44 / $1,949.84
| Professional | | $1,148.15 | $1,445.44 | $1,949.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $630.96 / $812.83 / $1,148.15
| Facility | | $630.96 | $812.83 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $1,096.48 / $3,090.30
| Professional | | $512.86 | $1,096.48 | $3,090.30 |