- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $326.68 / $469.33 / $1,940.11
| Professional | | $326.68 | $469.33 | $1,940.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,821.53 / $3,821.53 / $4,059.35
| Facility | | $3,821.53 | $3,821.53 | $4,059.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $385.84 / $617.91 / $1,332.34
| Professional | | $385.84 | $617.91 | $1,332.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $494.94 / $617.91 / $1,332.34
| Professional | | $494.94 | $617.91 | $1,332.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $410.17 / $522.03 / $1,635.30
| Professional | | $410.17 | $522.03 | $1,635.30 |