- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $535.01 / $678.78 / $679.37
| Professional | | $535.01 | $678.78 | $679.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $536.83 / $536.83 / $536.83
| Facility | | $536.83 | $536.83 | $536.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $456.31 / $536.83 / $536.83
| Professional | | $456.31 | $536.83 | $536.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,162.80 / $1,162.80 / $1,162.80
| Professional | | $1,162.80 | $1,162.80 | $1,162.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $760.28 / $760.28 / $894.45
| Professional | | $760.28 | $760.28 | $894.45 |