- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $703.27 / $763.92 / $1,089.66
| Professional | | $703.27 | $763.92 | $1,089.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $94.70 / $111.41 / $111.41
| Professional | | $94.70 | $111.41 | $111.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $816.59 / $816.59 / $816.59
| Facility | | $816.59 | $816.59 | $816.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $694.10 / $816.59 / $816.59
| Professional | | $694.10 | $816.59 | $816.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $385.01 / $530.84 / $1,049.42
| Professional | | $385.01 | $530.84 | $1,049.42 |