- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.27 / $340.11 / $1,724.92
| Professional | | $302.27 | $340.11 | $1,724.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $510.55 / $510.55 / $510.55
| Facility | | $510.55 | $510.55 | $510.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $342.39 / $510.55 / $953.70
| Professional | | $342.39 | $510.55 | $953.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $316.35 / $515.32 / $715.36
| Facility | | $316.35 | $515.32 | $715.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $334.73 / $514.94 / $868.26
| Professional | | $334.73 | $514.94 | $868.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.00 / $592.73 / $716.85
| Professional | | $478.00 | $592.73 | $716.85 |