- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.28 / $518.74 / $575.02
| Professional | | $407.28 | $518.74 | $575.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $515.28 / $654.37 / $1,043.94
| Professional | | $515.28 | $654.37 | $1,043.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $552.57 / $743.56 / $1,091.48
| Professional | | $552.57 | $743.56 | $1,091.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $656.63 / $759.72 / $1,165.45
| Professional | | $656.63 | $759.72 | $1,165.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.28 / $575.02 / $617.59
| Professional | | $407.28 | $575.02 | $617.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,905.54 / $3,905.54 / $3,905.54
| Facility | | $3,905.54 | $3,905.54 | $3,905.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $421.35 / $578.53 / $756.85
| Professional | | $421.35 | $578.53 | $756.85 |