- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $409.26 / $575.95 / $1,066.83
| Professional | | $409.26 | $575.95 | $1,066.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $840.94 / $840.94 / $840.94
| Facility | | $840.94 | $840.94 | $840.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $714.80 / $840.94 / $1,586.25
| Professional | | $714.80 | $840.94 | $1,586.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,162.80 / $1,162.80 / $1,162.80
| Professional | | $1,162.80 | $1,162.80 | $1,162.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $820.80 / $820.80 / $820.80
| Professional | | $820.80 | $820.80 | $820.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $518.55 / $671.05 / $1,260.21
| Professional | | $518.55 | $671.05 | $1,260.21 |