- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $684.35 / $1,012.62 / $1,210.20
| Professional | | $684.35 | $1,012.62 | $1,210.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,079.22 / $1,173.06 / $1,173.06
| Professional | | $1,079.22 | $1,173.06 | $1,173.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $95.77 / $95.77 / $95.77
| Facility | | $95.77 | $95.77 | $95.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $816.59 / $816.59 / $945.33
| Facility | | $816.59 | $816.59 | $945.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $92.43 / $816.59 / $1,151.25
| Professional | | $92.43 | $816.59 | $1,151.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $337.36 / $558.50 / $812.98
| Professional | | $337.36 | $558.50 | $812.98 |