- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $654.25 / $800.19 / $888.09
| Professional | | $654.25 | $800.19 | $888.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,117.08 / $2,859.39 / $3,385.18
| Facility | | $2,117.08 | $2,859.39 | $3,385.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $786.92 / $786.92 / $1,316.05
| Professional | | $786.92 | $786.92 | $1,316.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $832.50 / $832.50 / $866.11
| Facility | | $832.50 | $832.50 | $866.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $607.73 / $832.50 / $832.50
| Professional | | $607.73 | $832.50 | $832.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $563.33 / $800.41 / $1,245.04
| Professional | | $563.33 | $800.41 | $1,245.04 |