- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.05 / $426.58 / $758.58
| Professional | | $389.05 | $426.58 | $758.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $1,659.59 / $1,659.59
| Facility | | $1,659.59 | $1,659.59 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,412.54 / $1,698.24
| Professional | | $870.96 | $1,412.54 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $537.03 / $794.33 / $1,071.52
| Professional | | $537.03 | $794.33 | $1,071.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,659.59 / $5,370.32
| Facility | | $1,288.25 | $1,659.59 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $489.78 / $776.25 / $1,698.24
| Professional | | $489.78 | $776.25 | $1,698.24 |