- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $634.24 / $724.41 / $866.95
| Professional | | $634.24 | $724.41 | $866.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $85.77 / $85.77 / $857.67
| Facility | | $85.77 | $85.77 | $857.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $92.37 / $92.37 / $923.64
| Professional | | $92.37 | $92.37 | $923.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,212.78 / $1,212.78 / $1,212.78
| Facility | | $1,212.78 | $1,212.78 | $1,212.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $894.40 / $5,071.75 / $5,071.75
| Professional | | $894.40 | $5,071.75 | $5,071.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $553.28 / $803.46 / $1,411.59
| Professional | | $553.28 | $803.46 | $1,411.59 |