- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $535.92 / $712.56 / $2,627.30
| Professional | | $535.92 | $712.56 | $2,627.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $810.26 / $810.26 / $810.26
| Professional | | $810.26 | $810.26 | $810.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $810.26 / $810.26 / $810.26
| Facility | | $810.26 | $810.26 | $810.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $410.62 / $810.26 / $831.10
| Professional | | $410.62 | $810.26 | $831.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $401.93 / $552.65 / $810.26
| Facility | | $401.93 | $552.65 | $810.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $485.57 / $809.34 / $1,050.70
| Professional | | $485.57 | $809.34 | $1,050.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $675.86 / $805.28 / $920.32
| Professional | | $675.86 | $805.28 | $920.32 |