- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $509.48 / $525.25 / $691.57
| Professional | | $509.48 | $525.25 | $691.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,648.61 / $2,226.67 / $2,636.11
| Facility | | $1,648.61 | $2,226.67 | $2,636.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $647.37 / $761.61 / $1,054.46
| Professional | | $647.37 | $761.61 | $1,054.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $565.73 / $565.73 / $674.46
| Facility | | $565.73 | $565.73 | $674.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $412.98 / $565.73 / $565.73
| Professional | | $412.98 | $565.73 | $565.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $396.15 / $581.72 / $969.54
| Professional | | $396.15 | $581.72 | $969.54 |