- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $361.61 / $484.08 / $1,782.59
| Professional | | $361.61 | $484.08 | $1,782.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $551.55 / $551.55 / $551.55
| Facility | | $551.55 | $551.55 | $551.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $276.35 / $551.55 / $559.29
| Professional | | $276.35 | $551.55 | $559.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $273.85 / $363.05 / $551.55
| Facility | | $273.85 | $363.05 | $551.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $328.68 / $547.83 / $711.20
| Professional | | $328.68 | $547.83 | $711.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $456.37 / $543.76 / $700.86
| Professional | | $456.37 | $543.76 | $700.86 |