- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $544.79 / $605.17 / $663.47
| Professional | | $544.79 | $605.17 | $663.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,270.93 / $1,270.93 / $1,627.70
| Facility | | $1,270.93 | $1,270.93 | $1,627.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $558.11 / $867.15 / $1,243.83
| Professional | | $558.11 | $867.15 | $1,243.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $682.01 / $823.11 / $1,243.83
| Professional | | $682.01 | $823.11 | $1,243.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $650.41 / $781.23 / $2,271.09
| Professional | | $650.41 | $781.23 | $2,271.09 |