- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $315.06 / $420.90 / $1,612.72
| Professional | | $315.06 | $420.90 | $1,612.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $501.61 / $501.61 / $501.61
| Facility | | $501.61 | $501.61 | $501.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $255.97 / $501.61 / $504.59
| Professional | | $255.97 | $501.61 | $504.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $247.81 / $340.74 / $501.61
| Facility | | $247.81 | $340.74 | $501.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $304.08 / $501.61 / $658.00
| Professional | | $304.08 | $501.61 | $658.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $421.58 / $502.31 / $574.07
| Professional | | $421.58 | $502.31 | $574.07 |