- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $522.82 / $522.82 / $653.53
| Professional | | $522.82 | $522.82 | $653.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $274.91 / $444.86 / $960.20
| Facility | | $274.91 | $444.86 | $960.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $336.00 / $1,062.59 / $1,062.59
| Professional | | $336.00 | $1,062.59 | $1,062.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $336.00 / $336.00 / $336.00
| Facility | | $336.00 | $336.00 | $336.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $311.69 / $468.57 / $493.85
| Professional | | $311.69 | $468.57 | $493.85 |