- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $709.77 / $709.77 / $887.21
| Professional | | $709.77 | $709.77 | $887.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $477.46 / $678.61 / $789.62
| Facility | | $477.46 | $678.61 | $789.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,604.25 / $1,604.25 / $1,604.25
| Professional | | $1,604.25 | $1,604.25 | $1,604.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $319.00 / $319.00 / $319.00
| Facility | | $319.00 | $319.00 | $319.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.80 / $637.88 / $673.44
| Professional | | $346.80 | $637.88 | $673.44 |