- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $415.68 / $460.02 / $906.91
| Professional | | $415.68 | $460.02 | $906.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $427.34 / $427.34 / $1,021.77
| Facility | | $427.34 | $427.34 | $1,021.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $381.36 / $381.36 / $427.34
| Professional | | $381.36 | $381.36 | $427.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $427.34 / $427.34 / $1,021.77
| Facility | | $427.34 | $427.34 | $1,021.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $381.36 / $413.74 / $539.66
| Professional | | $381.36 | $413.74 | $539.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $381.36 / $381.36 / $381.36
| Professional | | $381.36 | $381.36 | $381.36 |