- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $540.94 / $540.94 / $603.16
| Professional | | $540.94 | $540.94 | $603.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $722.83 / $860.72 / $991.37
| Facility | | $722.83 | $860.72 | $991.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $608.03 / $608.03 / $950.04
| Professional | | $608.03 | $608.03 | $950.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $293.45 / $293.45 / $293.45
| Professional | | $293.45 | $293.45 | $293.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $927.07 / $927.07 / $1,110.72
| Professional | | $927.07 | $927.07 | $1,110.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $540.94 / $540.94 / $603.16
| Professional | | $540.94 | $540.94 | $603.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $400.50 / $1,303.17 / $1,633.67
| Professional | | $400.50 | $1,303.17 | $1,633.67 |