- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $436.52 / $512.86
| Professional | | $354.81 | $436.52 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $794.33 / $1,621.81
| Professional | | $630.96 | $794.33 | $1,621.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,023.29 / $1,023.29
| Facility | | $1,023.29 | $1,023.29 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $588.84 / $724.44
| Professional | | $588.84 | $588.84 | $724.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $512.86 / $512.86 / $512.86
| Facility | | $512.86 | $512.86 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.80 / $213.80 / $512.86
| Professional | | $213.80 | $213.80 | $512.86 |