- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.58 / $489.78 / $812.83
| Professional | | $426.58 | $489.78 | $812.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,380.38 / $1,380.38
| Facility | | $1,380.38 | $1,380.38 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,445.44 / $1,513.56
| Professional | | $954.99 | $1,445.44 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $537.03 / $891.25 / $1,479.11
| Professional | | $537.03 | $891.25 | $1,479.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $295.12 / $1,380.38 / $3,090.30
| Facility | | $295.12 | $1,380.38 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $891.25 / $1,737.80
| Professional | | $501.19 | $891.25 | $1,737.80 |