- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $338.84 / $676.08 / $1,230.27
| Professional | | $338.84 | $676.08 | $1,230.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $407.38 / $407.38 / $416.87
| Facility | | $407.38 | $407.38 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $407.38 / $758.58
| Professional | | $346.74 | $407.38 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,715.35 / $3,715.35 / $3,715.35
| Professional | | $3,715.35 | $3,715.35 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $758.58 / $758.58
| Professional | | $630.96 | $758.58 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $794.33 / $794.33
| Professional | | $794.33 | $794.33 | $794.33 |