- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $548.12 / $668.06 / $718.14
| Professional | | $548.12 | $668.06 | $718.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.06 / $1,122.06 / $1,122.06
| Facility | | $1,122.06 | $1,122.06 | $1,122.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $694.95 / $1,122.06 / $2,136.69
| Professional | | $694.95 | $1,122.06 | $2,136.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $491.63 / $762.39 / $1,439.27
| Facility | | $491.63 | $762.39 | $1,439.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $647.32 / $1,047.45 / $1,569.86
| Professional | | $647.32 | $1,047.45 | $1,569.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $905.14 / $1,064.86 / $1,657.66
| Professional | | $905.14 | $1,064.86 | $1,657.66 |