- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $171.15 / $392.08 / $645.07
| Professional | | $171.15 | $392.08 | $645.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $993.43 / $993.43 / $993.43
| Facility | | $993.43 | $993.43 | $993.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,046.20 / $1,046.20 / $1,046.20
| Facility | | $1,046.20 | $1,046.20 | $1,046.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $445.60 / $445.60 / $533.88
| Professional | | $445.60 | $445.60 | $533.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,046.20 / $1,046.20 / $1,046.20
| Facility | | $1,046.20 | $1,046.20 | $1,046.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $445.60 / $445.60 / $533.88
| Professional | | $445.60 | $445.60 | $533.88 |