- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $296.82 / $657.41 / $851.41
| Professional | | $296.82 | $657.41 | $851.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,788.74 / $1,987.49 / $2,829.48
| Facility | | $1,788.74 | $1,987.49 | $2,829.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $641.25 / $754.41 / $986.97
| Professional | | $641.25 | $754.41 | $986.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.83 / $812.83 / $952.31
| Facility | | $812.83 | $812.83 | $952.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $593.37 / $812.83 / $952.31
| Professional | | $593.37 | $812.83 | $952.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $543.83 / $686.96 / $1,144.94
| Professional | | $543.83 | $686.96 | $1,144.94 |