- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $247.88 / $344.00 / $396.40
| Professional | | $247.88 | $344.00 | $396.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,300.30 / $1,300.30 / $1,632.62
| Facility | | $1,300.30 | $1,300.30 | $1,632.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $432.41 / $509.72 / $1,229.39
| Professional | | $432.41 | $509.72 | $1,229.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $326.58 / $508.18 / $735.40
| Professional | | $326.58 | $508.18 | $735.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $393.25 / $485.10 / $735.40
| Professional | | $393.25 | $485.10 | $735.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $381.18 / $461.90 / $1,342.78
| Professional | | $381.18 | $461.90 | $1,342.78 |