- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $450.62 / $669.79 / $813.79
| Professional | | $450.62 | $669.79 | $813.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $825.58 / $825.58 / $1,014.01
| Professional | | $825.58 | $825.58 | $1,014.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $833.40 / $833.40 / $833.40
| Facility | | $833.40 | $833.40 | $833.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.49 / $833.40 / $1,571.25
| Professional | | $106.49 | $833.40 | $1,571.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $137.74 / $137.74 / $137.74
| Professional | | $137.74 | $137.74 | $137.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $526.16 / $668.58 / $1,114.30
| Professional | | $526.16 | $668.58 | $1,114.30 |