- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $426.58 / $524.81
| Professional | | $354.81 | $426.58 | $524.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $812.83 / $1,698.24
| Professional | | $660.69 | $812.83 | $1,698.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,047.13 / $1,047.13
| Facility | | $1,047.13 | $1,047.13 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $602.56 / $758.58
| Professional | | $602.56 | $602.56 | $758.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $524.81 / $524.81 / $524.81
| Facility | | $524.81 | $524.81 | $524.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.78 / $218.78 / $524.81
| Professional | | $218.78 | $218.78 | $524.81 |