- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $317.49 / $443.55 / $628.36
| Professional | | $317.49 | $443.55 | $628.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,565.82 / $3,565.82 / $4,428.89
| Facility | | $3,565.82 | $3,565.82 | $4,428.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $541.71 / $541.71 / $1,937.61
| Professional | | $541.71 | $541.71 | $1,937.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $475.32 / $706.70 / $1,210.99
| Professional | | $475.32 | $706.70 | $1,210.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $510.86 / $724.54 / $1,210.99
| Professional | | $510.86 | $724.54 | $1,210.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $531.33 / $748.22 / $2,211.14
| Professional | | $531.33 | $748.22 | $2,211.14 |