- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $906.94 / $1,273.20 / $1,372.56
| Professional | | $906.94 | $1,273.20 | $1,372.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $956.33 / $956.33 / $1,101.67
| Professional | | $956.33 | $956.33 | $1,101.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $469.00 / $469.00 / $469.00
| Facility | | $469.00 | $469.00 | $469.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.65 / $398.65 / $398.65
| Professional | | $398.65 | $398.65 | $398.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $494.06 / $785.09 / $1,072.86
| Professional | | $494.06 | $785.09 | $1,072.86 |