- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $621.76 / $754.00 / $812.35
| Professional | | $621.76 | $754.00 | $812.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,267.18 / $1,267.18 / $1,267.18
| Facility | | $1,267.18 | $1,267.18 | $1,267.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $784.84 / $1,267.18 / $2,413.02
| Professional | | $784.84 | $1,267.18 | $2,413.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $491.63 / $893.59 / $1,623.44
| Facility | | $491.63 | $893.59 | $1,623.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $730.14 / $1,181.35 / $1,772.56
| Professional | | $730.14 | $1,181.35 | $1,772.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.75 / $1,135.15 / $1,864.70
| Professional | | $933.75 | $1,135.15 | $1,864.70 |