- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $758.58 / $912.01
| Professional | | $501.19 | $758.58 | $912.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $758.58 / $758.58 / $1,148.15
| Facility | | $758.58 | $758.58 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $549.54 / $776.25
| Professional | | $549.54 | $549.54 | $776.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,412.54 / $1,621.81
| Professional | | $1,202.26 | $1,412.54 | $1,621.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $588.84 / $602.56 / $758.58
| Facility | | $588.84 | $602.56 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $537.03 / $912.01 / $3,235.94
| Professional | | $537.03 | $912.01 | $3,235.94 |