- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $676.08 / $741.31
| Professional | | $676.08 | $676.08 | $741.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,047.13 / $1,348.96
| Professional | | $1,023.29 | $1,047.13 | $1,348.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $537.03 / $537.03 / $537.03
| Facility | | $537.03 | $537.03 | $537.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $457.09 / $549.54
| Professional | | $457.09 | $457.09 | $549.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $676.08 / $676.08 / $1,047.13
| Facility | | $676.08 | $676.08 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,412.54 / $1,412.54
| Professional | | $1,412.54 | $1,412.54 | $1,412.54 |