- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $537.66 / $676.44 / $729.83
| Professional | | $537.66 | $676.44 | $729.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,739.83 / $2,349.92 / $2,782.03
| Facility | | $1,739.83 | $2,349.92 | $2,782.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $683.18 / $803.74 / $1,112.83
| Professional | | $683.18 | $803.74 | $1,112.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $741.89 / $741.89 / $741.89
| Facility | | $741.89 | $741.89 | $741.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $541.58 / $741.89 / $741.89
| Professional | | $541.58 | $741.89 | $741.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $480.70 / $613.91 / $1,023.20
| Professional | | $480.70 | $613.91 | $1,023.20 |