- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $309.03 / $436.52 / $676.08
| Professional | | $309.03 | $436.52 | $676.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $524.81 / $524.81 / $851.14
| Facility | | $524.81 | $524.81 | $851.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.81 / $933.25 / $1,318.26
| Professional | | $524.81 | $933.25 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,071.52 / $1,122.02
| Professional | | $1,071.52 | $1,071.52 | $1,122.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $1,071.52 / $1,230.27
| Professional | | $758.58 | $1,071.52 | $1,230.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $467.74 / $478.63 / $549.54
| Facility | | $467.74 | $478.63 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.38 / $794.33 / $1,174.90
| Professional | | $407.38 | $794.33 | $1,174.90 |