- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $416.87 / $575.44 / $1,621.81
| Professional | | $416.87 | $575.44 | $1,621.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $2,137.96 / $2,454.71
| Facility | | $1,548.82 | $2,137.96 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $446.68 / $602.56 / $1,122.02
| Professional | | $446.68 | $602.56 | $1,122.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $616.60 / $616.60 / $691.83
| Facility | | $616.60 | $616.60 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $501.19 / $691.83
| Professional | | $501.19 | $501.19 | $691.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $630.96 / $741.31 / $1,288.25
| Facility | | $630.96 | $741.31 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.63 / $602.56 / $891.25
| Professional | | $478.63 | $602.56 | $891.25 |