- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.02 / $585.34 / $591.91
| Professional | | $316.02 | $585.34 | $591.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $486.10 / $486.10 / $486.10
| Professional | | $486.10 | $486.10 | $486.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $461.38 / $461.38 / $461.38
| Facility | | $461.38 | $461.38 | $461.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $392.17 / $530.85 / $1,088.44
| Professional | | $392.17 | $530.85 | $1,088.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $212.34 / $349.43 / $508.58
| Professional | | $212.34 | $349.43 | $508.58 |