- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $527.23 / $527.23 / $584.23
| Professional | | $527.23 | $527.23 | $584.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $876.34 / $876.34 / $876.34
| Facility | | $876.34 | $876.34 | $876.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $818.98 / $818.98 / $1,023.72
| Professional | | $818.98 | $818.98 | $1,023.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $854.96 / $854.96 / $854.96
| Facility | | $854.96 | $854.96 | $854.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $249.36 / $427.48 / $1,027.59
| Professional | | $249.36 | $427.48 | $1,027.59 |