- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $494.38 / $663.88 / $663.88
| Professional | | $494.38 | $663.88 | $663.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,251.39 / $1,589.06 / $1,597.01
| Professional | | $1,251.39 | $1,589.06 | $1,597.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $811.55 / $811.55 / $1,014.43
| Professional | | $811.55 | $811.55 | $1,014.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $423.75 / $508.50 / $663.88
| Facility | | $423.75 | $508.50 | $663.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $423.75 / $904.00 / $3,517.13
| Professional | | $423.75 | $904.00 | $3,517.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $720.38 / $904.00 / $1,024.06
| Professional | | $720.38 | $904.00 | $1,024.06 |