- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $637.07 / $824.30 / $864.77
| Professional | | $637.07 | $824.30 | $864.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,061.48 / $2,784.28 / $3,296.26
| Facility | | $2,061.48 | $2,784.28 | $3,296.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $651.30 / $766.25 / $1,281.48
| Professional | | $651.30 | $766.25 | $1,281.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $969.19 / $969.19 / $969.19
| Facility | | $969.19 | $969.19 | $969.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.51 / $707.51 / $707.51
| Professional | | $707.51 | $707.51 | $707.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $580.30 / $727.41 / $1,212.34
| Professional | | $580.30 | $727.41 | $1,212.34 |