- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $315.89 / $429.58 / $1,559.74
| Professional | | $315.89 | $429.58 | $1,559.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $550.51 / $550.51 / $550.51
| Facility | | $550.51 | $550.51 | $550.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $343.78 / $550.51 / $1,102.57
| Professional | | $343.78 | $550.51 | $1,102.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $354.28 / $520.47 / $861.47
| Facility | | $354.28 | $520.47 | $861.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $465.63 / $787.45 / $1,363.75
| Professional | | $465.63 | $787.45 | $1,363.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $638.54 / $779.99 / $1,024.22
| Professional | | $638.54 | $779.99 | $1,024.22 |