- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $869.04 / $891.53 / $947.33
| Professional | | $869.04 | $891.53 | $947.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $93.76 / $115.40 / $866.79
| Facility | | $93.76 | $115.40 | $866.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.76 / $100.98 / $933.47
| Professional | | $93.76 | $100.98 | $933.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,042.44 / $1,042.44 / $1,603.87
| Facility | | $1,042.44 | $1,042.44 | $1,603.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $119.94 / $1,042.44 / $6,707.27
| Professional | | $119.94 | $1,042.44 | $6,707.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $523.23 / $719.71 / $1,155.71
| Professional | | $523.23 | $719.71 | $1,155.71 |