- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $625.27 / $715.00 / $905.45
| Professional | | $625.27 | $715.00 | $905.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,035.63 / $1,035.63 / $1,035.63
| Facility | | $1,035.63 | $1,035.63 | $1,035.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,035.63 / $1,035.63 / $1,035.63
| Professional | | $1,035.63 | $1,035.63 | $1,035.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $670.25 / $670.25 / $971.18
| Facility | | $670.25 | $670.25 | $971.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $569.71 / $670.25 / $880.23
| Professional | | $569.71 | $670.25 | $880.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $367.64 / $643.38 / $1,380.91
| Professional | | $367.64 | $643.38 | $1,380.91 |