- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $588.84 / $645.65
| Professional | | $457.09 | $588.84 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,071.52 / $2,187.76
| Professional | | $870.96 | $1,071.52 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,380.38 / $1,380.38
| Facility | | $1,380.38 | $1,380.38 | $1,380.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $691.83 / $691.83 / $691.83
| Facility | | $691.83 | $691.83 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.40 / $288.40 / $691.83
| Professional | | $288.40 | $288.40 | $691.83 |