- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $515.77 / $648.92 / $700.12
| Professional | | $515.77 | $648.92 | $700.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,669.00 / $2,254.21 / $2,668.73
| Facility | | $1,669.00 | $2,254.21 | $2,668.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $664.67 / $664.67 / $1,067.52
| Professional | | $664.67 | $664.67 | $1,067.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $782.41 / $782.41 / $782.41
| Facility | | $782.41 | $782.41 | $782.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $571.16 / $782.41 / $782.41
| Professional | | $571.16 | $782.41 | $782.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $456.84 / $588.91 / $981.54
| Professional | | $456.84 | $588.91 | $981.54 |