- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $419.86 / $576.71 / $1,133.60
| Professional | | $419.86 | $576.71 | $1,133.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $359.59 / $359.59 / $359.59
| Facility | | $359.59 | $359.59 | $359.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $305.64 / $305.64 / $1,687.50
| Professional | | $305.64 | $305.64 | $1,687.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $473.84 / $473.84 / $473.84
| Professional | | $473.84 | $473.84 | $473.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $56.66 / $911.76 / $911.76
| Professional | | $56.66 | $911.76 | $911.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $519.47 / $686.46 / $1,011.64
| Professional | | $519.47 | $686.46 | $1,011.64 |