- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.23 / $371.54 / $602.56
| Professional | | $316.23 | $371.54 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,122.02 / $1,202.26
| Professional | | $1,122.02 | $1,122.02 | $1,202.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $316.23 / $426.58 / $660.69
| Facility | | $316.23 | $426.58 | $660.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.26 / $316.23 / $602.56
| Professional | | $60.26 | $316.23 | $602.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $316.23 / $398.11 / $602.56
| Facility | | $316.23 | $398.11 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.26 / $1,122.02 / $1,202.26
| Professional | | $60.26 | $1,122.02 | $1,202.26 |