- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $491.17 / $584.46 / $660.35
| Professional | | $491.17 | $584.46 | $660.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,026.35 / $1,026.35 / $1,026.35
| Facility | | $1,026.35 | $1,026.35 | $1,026.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $635.69 / $1,026.35 / $1,954.43
| Professional | | $635.69 | $1,026.35 | $1,954.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $412.89 / $705.22 / $1,257.92
| Facility | | $412.89 | $705.22 | $1,257.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $595.24 / $915.42 / $1,361.23
| Professional | | $595.24 | $915.42 | $1,361.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $555.98 / $749.75 / $1,207.83
| Professional | | $555.98 | $749.75 | $1,207.83 |