- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $323.59 / $489.78 / $562.34
| Professional | | $323.59 | $489.78 | $562.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $512.86 / $512.86 / $645.65
| Facility | | $512.86 | $512.86 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $537.03 / $602.56 / $870.96
| Professional | | $537.03 | $602.56 | $870.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $478.63 / $524.81 / $1,621.81
| Facility | | $478.63 | $524.81 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.58 / $588.84 / $1,047.13
| Professional | | $426.58 | $588.84 | $1,047.13 |