- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $375.31 / $375.31 / $657.26
| Professional | | $375.31 | $375.31 | $657.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $733.02 / $733.02 / $733.02
| Facility | | $733.02 | $733.02 | $733.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $733.02 / $733.02 / $733.02
| Professional | | $733.02 | $733.02 | $733.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $485.57 / $485.57 / $888.06
| Facility | | $485.57 | $485.57 | $888.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.47 / $354.47 / $485.57
| Professional | | $354.47 | $354.47 | $485.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $338.45 / $374.47 / $750.62
| Professional | | $338.45 | $374.47 | $750.62 |