- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $349.85 / $615.11 / $3,272.03
| Professional | | $349.85 | $615.11 | $3,272.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $851.73 / $851.73 / $851.73
| Facility | | $851.73 | $851.73 | $851.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $243.67 / $699.82 / $1,143.33
| Professional | | $243.67 | $699.82 | $1,143.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $851.73 / $851.73 / $851.73
| Facility | | $851.73 | $851.73 | $851.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $243.67 / $579.36 / $1,143.33
| Professional | | $243.67 | $579.36 | $1,143.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $222.27 / $508.87 / $1,175.69
| Professional | | $222.27 | $508.87 | $1,175.69 |