- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $505.12 / $631.76 / $749.27
| Professional | | $505.12 | $631.76 | $749.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,040.88 / $4,040.88 / $5,018.97
| Facility | | $4,040.88 | $4,040.88 | $5,018.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $734.47 / $865.77 / $2,175.34
| Professional | | $734.47 | $865.77 | $2,175.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $656.47 / $811.59 / $1,336.50
| Professional | | $656.47 | $811.59 | $1,336.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.52 / $811.59 / $1,336.50
| Professional | | $616.52 | $811.59 | $1,336.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.91 / $839.44 / $2,440.31
| Professional | | $676.91 | $839.44 | $2,440.31 |