- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $254.66 / $297.83 / $1,449.88
| Professional | | $254.66 | $297.83 | $1,449.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $438.52 / $438.52 / $438.52
| Facility | | $438.52 | $438.52 | $438.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $342.35 / $438.52 / $438.52
| Professional | | $342.35 | $438.52 | $438.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $438.52 / $529.75 / $545.22
| Facility | | $438.52 | $529.75 | $545.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $269.80 / $382.22 / $583.79
| Professional | | $269.80 | $382.22 | $583.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $415.64 / $497.40 / $771.45
| Professional | | $415.64 | $497.40 | $771.45 |