- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $691.83 / $891.25
| Professional | | $501.19 | $691.83 | $891.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,202.26 / $1,202.26
| Facility | | $1,202.26 | $1,202.26 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $831.76 / $1,023.29
| Professional | | $831.76 | $831.76 | $1,023.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $724.44 / $724.44 / $724.44
| Facility | | $724.44 | $724.44 | $724.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $251.19 / $251.19 / $251.19
| Facility | | $251.19 | $251.19 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.23 / $436.52 / $1,096.48
| Professional | | $316.23 | $436.52 | $1,096.48 |