- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $851.14 / $1,071.52
| Professional | | $616.60 | $851.14 | $1,071.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $891.25 / $1,202.26
| Facility | | $891.25 | $891.25 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $660.69 / $912.01
| Professional | | $660.69 | $660.69 | $912.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,548.82 / $1,905.46
| Professional | | $1,288.25 | $1,548.82 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $870.96 / $954.99 / $1,122.02
| Facility | | $870.96 | $954.99 | $1,122.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $1,230.27 / $3,467.37
| Professional | | $575.44 | $1,230.27 | $3,467.37 |