- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $357.10 / $484.74 / $505.24
| Professional | | $357.10 | $484.74 | $505.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,155.53 / $1,560.71 / $1,847.69
| Facility | | $1,155.53 | $1,560.71 | $1,847.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $365.08 / $429.51 / $718.33
| Professional | | $365.08 | $429.51 | $718.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $510.69 / $510.69 / $510.69
| Facility | | $510.69 | $510.69 | $510.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $434.09 / $510.69 / $510.69
| Professional | | $434.09 | $510.69 | $510.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $368.52 / $520.96 / $679.56
| Professional | | $368.52 | $520.96 | $679.56 |