- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $468.35 / $468.35 / $820.20
| Professional | | $468.35 | $468.35 | $820.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $914.74 / $914.74 / $914.74
| Facility | | $914.74 | $914.74 | $914.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $914.74 / $914.74 / $914.74
| Professional | | $914.74 | $914.74 | $914.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $502.54 / $502.54 / $772.77
| Facility | | $502.54 | $502.54 | $772.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $427.16 / $427.16 / $502.54
| Professional | | $427.16 | $427.16 | $502.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.77 / $467.30 / $540.07
| Professional | | $316.77 | $467.30 | $540.07 |