- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $575.44 / $851.14
| Professional | | $575.44 | $575.44 | $851.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,047.13 / $1,047.13
| Facility | | $1,047.13 | $1,047.13 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $707.95 / $1,318.26
| Professional | | $371.54 | $707.95 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $851.14 / $1,698.24
| Professional | | $776.25 | $851.14 | $1,698.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $51.29 / $380.19 / $676.08
| Facility | | $51.29 | $380.19 | $676.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $436.52 / $977.24 / $1,318.26
| Professional | | $436.52 | $977.24 | $1,318.26 |