- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $794.33 / $812.83
| Professional | | $645.65 | $794.33 | $812.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,230.27 / $1,230.27
| Facility | | $1,230.27 | $1,230.27 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,230.27 / $1,230.27
| Professional | | $1,230.27 | $1,230.27 | $1,230.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $851.14 / $1,096.48 / $2,570.40
| Facility | | $851.14 | $1,096.48 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,096.48 / $2,570.40
| Professional | | $851.14 | $1,096.48 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $758.58 / $1,230.27 / $1,862.09
| Facility | | $758.58 | $1,230.27 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $758.58 / $1,230.27
| Professional | | $79.43 | $758.58 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $354.81 / $851.14
| Professional | | $354.81 | $354.81 | $851.14 |