- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $522.63 / $529.69 / $755.69
| Professional | | $522.63 | $529.69 | $755.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $860.24 / $860.24 / $1,030.66
| Professional | | $860.24 | $860.24 | $1,030.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $522.63 / $665.98 / $1,024.06
| Facility | | $522.63 | $665.98 | $1,024.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $296.63 / $296.63 / $3,517.13
| Professional | | $296.63 | $296.63 | $3,517.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $296.63 / $296.63 / $706.25
| Professional | | $296.63 | $296.63 | $706.25 |