- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $408.05 / $547.16 / $618.77
| Professional | | $408.05 | $547.16 | $618.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $911.74 / $911.74 / $911.74
| Facility | | $911.74 | $911.74 | $911.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $564.70 / $911.74 / $1,736.15
| Professional | | $564.70 | $911.74 | $1,736.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $418.14 / $811.27 / $1,298.03
| Facility | | $418.14 | $811.27 | $1,298.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $600.02 / $911.74 / $1,274.68
| Professional | | $600.02 | $911.74 | $1,274.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $681.14 / $846.48 / $1,629.40
| Professional | | $681.14 | $846.48 | $1,629.40 |