- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $864.99 / $1,031.48 / $1,175.41
| Professional | | $864.99 | $1,031.48 | $1,175.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $863.94 / $939.07 / $939.07
| Professional | | $863.94 | $939.07 | $939.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,042.44 / $1,042.44 / $1,042.44
| Facility | | $1,042.44 | $1,042.44 | $1,042.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $119.94 / $886.07 / $2,090.63
| Professional | | $119.94 | $886.07 | $2,090.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $428.41 / $595.12 / $1,024.93
| Professional | | $428.41 | $595.12 | $1,024.93 |