- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $638.04 / $696.07 / $915.89
| Professional | | $638.04 | $696.07 | $915.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,011.68 / $1,011.68 / $1,011.68
| Facility | | $1,011.68 | $1,011.68 | $1,011.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,011.68 / $1,011.68 / $1,011.68
| Professional | | $1,011.68 | $1,011.68 | $1,011.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $394.97 / $394.97 / $1,040.75
| Facility | | $394.97 | $394.97 | $1,040.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.33 / $394.97 / $897.69
| Professional | | $288.33 | $394.97 | $897.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $365.36 / $583.45 / $1,106.24
| Professional | | $365.36 | $583.45 | $1,106.24 |