- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $631.20 / $837.59 / $1,905.20
| Professional | | $631.20 | $837.59 | $1,905.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $697.01 / $1,025.01 / $1,025.01
| Professional | | $697.01 | $1,025.01 | $1,025.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $541.00 / $541.00 / $541.00
| Facility | | $541.00 | $541.00 | $541.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $698.44 / $932.32 / $1,272.48
| Professional | | $698.44 | $932.32 | $1,272.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $682.96 / $852.24 / $1,102.25
| Professional | | $682.96 | $852.24 | $1,102.25 |