- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $234.42 / $467.74 / $758.58
| Professional | | $234.42 | $467.74 | $758.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $3,311.31 / $4,168.69
| Facility | | $1,380.38 | $3,311.31 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $758.58 / $758.58
| Professional | | $645.65 | $758.58 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.40 / $630.96 / $1,778.28
| Professional | | $288.40 | $630.96 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $660.69 / $1,230.27
| Professional | | $501.19 | $660.69 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.19 / $549.54 / $1,071.52
| Professional | | $251.19 | $549.54 | $1,071.52 |