- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.58 / $478.63 / $851.14
| Professional | | $426.58 | $478.63 | $851.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $676.08 / $676.08 / $676.08
| Facility | | $676.08 | $676.08 | $676.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,412.54 / $1,698.24
| Professional | | $933.25 | $1,412.54 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $831.76 / $1,348.96
| Professional | | $512.86 | $831.76 | $1,348.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $295.12 / $524.81 / $3,090.30
| Facility | | $295.12 | $524.81 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.74 / $831.76 / $1,737.80
| Professional | | $467.74 | $831.76 | $1,737.80 |