- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $348.12 / $432.16 / $786.06
| Professional | | $348.12 | $432.16 | $786.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $581.42 / $581.42 / $763.12
| Facility | | $581.42 | $581.42 | $763.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $494.22 / $581.42 / $1,038.38
| Professional | | $494.22 | $581.42 | $1,038.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $739.84 / $739.84 / $1,038.27
| Professional | | $739.84 | $739.84 | $1,038.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $582.15 / $582.15 / $582.15
| Professional | | $582.15 | $582.15 | $582.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $392.95 / $509.38 / $1,046.67
| Professional | | $392.95 | $509.38 | $1,046.67 |