- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $649.57 / $780.58 / $920.24
| Professional | | $649.57 | $780.58 | $920.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,520.64 / $4,520.64 / $5,789.62
| Facility | | $4,520.64 | $4,520.64 | $5,789.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $669.40 / $1,069.84 / $1,533.09
| Professional | | $669.40 | $1,069.84 | $1,533.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $766.65 / $1,069.96 / $1,533.09
| Professional | | $766.65 | $1,069.96 | $1,533.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $801.18 / $962.91 / $2,799.24
| Professional | | $801.18 | $962.91 | $2,799.24 |