- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $512.86 / $512.86 / $8,511.38
| Facility | | $512.86 | $512.86 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $512.86 / $512.86
| Professional | | $512.86 | $512.86 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $912.01 / $1,479.11
| Professional | | $707.95 | $912.01 | $1,479.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $512.86 / $512.86 / $1,548.82
| Facility | | $512.86 | $512.86 | $1,548.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,943.28 / $8,912.51 / $8,912.51
| Facility | | $7,943.28 | $8,912.51 | $8,912.51 |