- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $758.58 / $977.24
| Professional | | $575.44 | $758.58 | $977.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,023.29 / $1,288.25
| Professional | | $812.83 | $1,023.29 | $1,288.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $707.95 / $707.95 / $707.95
| Facility | | $707.95 | $707.95 | $707.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,548.82 / $2,570.40
| Professional | | $1,258.93 | $1,548.82 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $912.01 / $977.24
| Professional | | $575.44 | $912.01 | $977.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,380.38 / $2,290.87
| Professional | | $954.99 | $1,380.38 | $2,290.87 |