- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.74 / $741.31 / $1,096.48
| Professional | | $467.74 | $741.31 | $1,096.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $602.56 / $602.56 / $602.56
| Facility | | $602.56 | $602.56 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $602.56 / $1,621.81
| Professional | | $512.86 | $602.56 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,096.48 / $1,096.48
| Professional | | $1,096.48 | $1,096.48 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $933.25 / $954.99
| Professional | | $933.25 | $933.25 | $954.99 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $70.79 / $524.81 / $1,445.44
| Facility | | $70.79 | $524.81 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $537.03 / $758.58 / $1,288.25
| Professional | | $537.03 | $758.58 | $1,288.25 |