- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $378.84 / $542.50 / $2,869.87
| Professional | | $378.84 | $542.50 | $2,869.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $882.29 / $882.29 / $882.29
| Facility | | $882.29 | $882.29 | $882.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $505.25 / $882.29 / $1,500.12
| Professional | | $505.25 | $882.29 | $1,500.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $525.44 / $667.29 / $881.07
| Facility | | $525.44 | $667.29 | $881.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $541.54 / $902.62 / $1,504.09
| Professional | | $541.54 | $902.62 | $1,504.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $728.47 / $892.63 / $1,154.14
| Professional | | $728.47 | $892.63 | $1,154.14 |