- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $776.25 / $977.24
| Professional | | $660.69 | $776.25 | $977.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $1,071.52 / $1,230.27
| Facility | | $891.25 | $1,071.52 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $776.25 / $776.25
| Professional | | $588.84 | $776.25 | $776.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,290.87 / $2,290.87
| Facility | | $2,290.87 | $2,290.87 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $1,000.00 / $1,621.81
| Professional | | $724.44 | $1,000.00 | $1,621.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $776.25 / $776.25 / $776.25
| Facility | | $776.25 | $776.25 | $776.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $489.78 / $870.96 / $1,348.96
| Professional | | $489.78 | $870.96 | $1,348.96 |