- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $416.87 / $549.54 / $812.83
| Professional | | $416.87 | $549.54 | $812.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $562.34 / $562.34 / $831.76
| Facility | | $562.34 | $562.34 | $831.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $933.25 / $1,318.26
| Professional | | $562.34 | $933.25 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,071.52 / $1,122.02
| Professional | | $1,071.52 | $1,071.52 | $1,122.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $1,071.52 / $1,230.27
| Professional | | $630.96 | $1,071.52 | $1,230.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $446.68 / $457.09 / $562.34
| Facility | | $446.68 | $457.09 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $537.03 / $758.58 / $1,148.15
| Professional | | $537.03 | $758.58 | $1,148.15 |