- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $577.16 / $577.16 / $721.45
| Professional | | $577.16 | $577.16 | $721.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,251.36 / $1,251.36 / $1,251.36
| Facility | | $1,251.36 | $1,251.36 | $1,251.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $401.00 / $1,522.86 / $1,522.86
| Professional | | $401.00 | $1,522.86 | $1,522.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $387.90 / $401.00 / $487.20
| Facility | | $387.90 | $401.00 | $487.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $382.61 / $487.20 / $659.73
| Professional | | $382.61 | $487.20 | $659.73 |