- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $483.68 / $505.01 / $2,339.69
| Professional | | $483.68 | $505.01 | $2,339.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $706.15 / $706.15 / $706.15
| Facility | | $706.15 | $706.15 | $706.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.82 / $706.15 / $706.15
| Professional | | $630.82 | $706.15 | $706.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $706.15 / $706.15 / $706.15
| Facility | | $706.15 | $706.15 | $706.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $432.84 / $629.38 / $936.60
| Professional | | $432.84 | $629.38 | $936.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $684.84 / $790.20 / $1,233.96
| Professional | | $684.84 | $790.20 | $1,233.96 |