- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $517.16 / $517.16 / $646.46
| Professional | | $517.16 | $517.16 | $646.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,400.34 / $1,636.41 / $2,639.47
| Facility | | $1,400.34 | $1,636.41 | $2,639.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $336.75 / $582.75 / $728.44
| Professional | | $336.75 | $582.75 | $728.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $584.42 / $584.42 / $584.42
| Facility | | $584.42 | $584.42 | $584.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $58.40 / $58.40 / $58.40
| Professional | | $58.40 | $58.40 | $58.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $90.00 / $90.00 / $90.00
| Facility | | $90.00 | $90.00 | $90.00 |