- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $383.12 / $519.27 / $935.55
| Professional | | $383.12 | $519.27 | $935.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,071.71 / $2,071.71 / $2,493.21
| Facility | | $2,071.71 | $2,071.71 | $2,493.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $489.91 / $735.29 / $1,658.08
| Professional | | $489.91 | $735.29 | $1,658.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $526.70 / $751.01 / $1,658.08
| Professional | | $526.70 | $751.01 | $1,658.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $587.85 / $723.02 / $2,330.96
| Professional | | $587.85 | $723.02 | $2,330.96 |