- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.05 / $549.54 / $741.31
| Professional | | $389.05 | $549.54 | $741.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,096.48 / $1,202.26
| Facility | | $1,096.48 | $1,096.48 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $724.44 / $1,071.52
| Professional | | $724.44 | $724.44 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $269.15 / $512.86 / $1,071.52
| Professional | | $269.15 | $512.86 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $489.78 / $489.78 / $1,071.52
| Professional | | $489.78 | $489.78 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.40 / $707.95 / $1,174.90
| Professional | | $288.40 | $707.95 | $1,174.90 |