- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $374.24 / $470.83 / $508.00
| Professional | | $374.24 | $470.83 | $508.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,211.02 / $1,635.62 / $1,936.38
| Facility | | $1,211.02 | $1,635.62 | $1,936.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $382.61 / $450.13 / $752.81
| Professional | | $382.61 | $450.13 | $752.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $624.54 / $624.54 / $624.54
| Facility | | $624.54 | $624.54 | $624.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $455.91 / $624.54 / $624.54
| Professional | | $455.91 | $624.54 | $624.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $386.21 / $545.97 / $712.19
| Professional | | $386.21 | $545.97 | $712.19 |