- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $578.62 / $713.71 / $2,718.43
| Professional | | $578.62 | $713.71 | $2,718.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $833.39 / $833.39 / $833.39
| Facility | | $833.39 | $833.39 | $833.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $528.39 / $833.39 / $922.47
| Professional | | $528.39 | $833.39 | $922.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $410.32 / $564.19 / $944.23
| Facility | | $410.32 | $564.19 | $944.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $511.13 / $833.39 / $1,121.40
| Professional | | $511.13 | $833.39 | $1,121.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $792.54 / $913.13 / $1,057.31
| Professional | | $792.54 | $913.13 | $1,057.31 |