- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $501.19 / $812.83
| Professional | | $354.81 | $501.19 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $616.60 / $616.60
| Professional | | $616.60 | $616.60 | $616.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $512.86 / $512.86 / $1,380.38
| Facility | | $512.86 | $512.86 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $436.52 / $436.52 / $1,023.29
| Professional | | $436.52 | $436.52 | $1,023.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $537.03 / $616.60 / $1,122.02
| Facility | | $537.03 | $616.60 | $1,122.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $269.15 / $407.38 / $616.60
| Professional | | $269.15 | $407.38 | $616.60 |