- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.97 / $251.19 / $426.58
| Professional | | $181.97 | $251.19 | $426.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,202.26 / $1,202.26
| Facility | | $1,202.26 | $1,202.26 | $1,202.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $891.25 / $891.25
| Facility | | $891.25 | $891.25 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.47 / $309.03 / $741.31
| Professional | | $245.47 | $309.03 | $741.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.80 / $288.40 / $794.33
| Professional | | $213.80 | $288.40 | $794.33 |