- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.96 / $778.50 / $854.70
| Professional | | $645.96 | $778.50 | $854.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $425.15 / $425.15 / $425.15
| Facility | | $425.15 | $425.15 | $425.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.34 / $938.08 / $1,679.89
| Professional | | $660.34 | $938.08 | $1,679.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,320.00 / $1,320.00 / $1,320.00
| Facility | | $1,320.00 | $1,320.00 | $1,320.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $757.45 / $1,120.85 / $2,047.95
| Professional | | $757.45 | $1,120.85 | $2,047.95 |