- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.81 / $776.25 / $891.25
| Professional | | $524.81 | $776.25 | $891.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,047.13 / $1,174.90
| Facility | | $1,047.13 | $1,047.13 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $776.25 / $1,047.13
| Professional | | $776.25 | $776.25 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,288.25 / $1,698.24
| Professional | | $1,258.93 | $1,288.25 | $1,698.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $630.96 / $794.33 / $977.24
| Facility | | $630.96 | $794.33 | $977.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $977.24 / $3,311.31
| Professional | | $549.54 | $977.24 | $3,311.31 |