- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $580.09 / $580.09 / $907.05
| Professional | | $580.09 | $580.09 | $907.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,011.60 / $1,011.60 / $1,011.60
| Facility | | $1,011.60 | $1,011.60 | $1,011.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,011.60 / $1,011.60 / $1,011.60
| Professional | | $1,011.60 | $1,011.60 | $1,011.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $732.96 / $732.96 / $1,167.39
| Facility | | $732.96 | $732.96 | $1,167.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $535.05 / $535.05 / $1,028.25
| Professional | | $535.05 | $535.05 | $1,028.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.08 / $516.79 / $573.73
| Professional | | $467.08 | $516.79 | $573.73 |