- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $483.82 / $677.11 / $885.51
| Professional | | $483.82 | $677.11 | $885.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,797.56 / $3,797.56 / $4,716.72
| Facility | | $3,797.56 | $3,797.56 | $4,716.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $847.14 / $998.59 / $2,498.56
| Professional | | $847.14 | $998.59 | $2,498.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $612.85 / $958.83 / $1,638.42
| Professional | | $612.85 | $958.83 | $1,638.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $747.10 / $1,023.98 / $1,638.42
| Professional | | $747.10 | $1,023.98 | $1,638.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $844.87 / $1,012.31 / $2,991.58
| Professional | | $844.87 | $1,012.31 | $2,991.58 |