- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $598.11 / $688.54 / $968.13
| Professional | | $598.11 | $688.54 | $968.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,927.04 / $4,927.04 / $6,119.56
| Facility | | $4,927.04 | $4,927.04 | $6,119.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $862.33 / $862.33 / $1,768.93
| Professional | | $862.33 | $862.33 | $1,768.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $542.66 / $823.22 / $1,768.93
| Professional | | $542.66 | $823.22 | $1,768.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $542.66 / $823.22 / $1,768.93
| Professional | | $542.66 | $823.22 | $1,768.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $508.11 / $725.45 / $2,171.16
| Professional | | $508.11 | $725.45 | $2,171.16 |