- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $563.95 / $742.87 / $768.78
| Professional | | $563.95 | $742.87 | $768.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $622.10 / $676.20 / $676.20
| Professional | | $622.10 | $676.20 | $676.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,013.42 / $2,355.54 / $2,355.54
| Facility | | $1,013.42 | $2,355.54 | $2,355.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $73.42 / $2,002.21 / $2,355.54
| Professional | | $73.42 | $2,002.21 | $2,355.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $291.45 / $419.12 / $664.07
| Professional | | $291.45 | $419.12 | $664.07 |