- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $553.67 / $897.57 / $907.65
| Professional | | $553.67 | $897.57 | $907.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $975.43 / $975.43 / $975.43
| Professional | | $975.43 | $975.43 | $975.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $670.25 / $670.25 / $897.30
| Facility | | $670.25 | $670.25 | $897.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $670.25 / $670.25 / $1,149.75
| Professional | | $670.25 | $670.25 | $1,149.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $367.64 / $572.00 / $1,098.84
| Professional | | $367.64 | $572.00 | $1,098.84 |