- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $435.70 / $472.98 / $575.55
| Professional | | $435.70 | $472.98 | $575.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,009.28 / $1,075.36 / $1,194.85
| Facility | | $1,009.28 | $1,075.36 | $1,194.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $423.97 / $586.80 / $783.65
| Professional | | $423.97 | $586.80 | $783.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,130.17 / $2,130.17 / $2,130.17
| Facility | | $2,130.17 | $2,130.17 | $2,130.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $493.56 / $659.58 / $1,368.29
| Professional | | $493.56 | $659.58 | $1,368.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $439.14 / $589.85 / $879.20
| Professional | | $439.14 | $589.85 | $879.20 |