- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $545.83 / $545.83 / $545.83
| Professional | | $545.83 | $545.83 | $545.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,108.73 / $1,153.07 / $2,480.71
| Facility | | $1,108.73 | $1,153.07 | $2,480.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $791.71 / $791.71 / $870.10
| Professional | | $791.71 | $791.71 | $870.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $784.63 / $1,386.89 / $1,386.89
| Professional | | $784.63 | $1,386.89 | $1,386.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $286.56 / $409.37 / $1,084.83
| Professional | | $286.56 | $409.37 | $1,084.83 |