- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.23 / $426.58 / $691.83
| Professional | | $316.23 | $426.58 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $549.54 / $549.54
| Professional | | $549.54 | $549.54 | $549.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $524.81 / $524.81 / $1,258.93
| Facility | | $524.81 | $524.81 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.05 / $389.05 / $954.99
| Professional | | $389.05 | $389.05 | $954.99 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $489.78 / $562.34 / $1,000.00
| Facility | | $489.78 | $562.34 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.47 / $371.54 / $562.34
| Professional | | $245.47 | $371.54 | $562.34 |