- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $386.96 / $401.47 / $1,119.45
| Professional | | $386.96 | $401.47 | $1,119.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $627.49 / $711.15 / $1,248.70
| Facility | | $627.49 | $711.15 | $1,248.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $411.15 / $411.15 / $463.54
| Professional | | $411.15 | $411.15 | $463.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $401.47 / $427.27 / $857.56
| Facility | | $401.47 | $427.27 | $857.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $411.15 / $463.54 / $503.85
| Professional | | $411.15 | $463.54 | $503.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $403.08 / $403.08 / $403.08
| Professional | | $403.08 | $403.08 | $403.08 |