- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $626.66 / $850.66 / $912.99
| Professional | | $626.66 | $850.66 | $912.99 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,027.83 / $2,738.84 / $3,242.46
| Facility | | $2,027.83 | $2,738.84 | $3,242.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $640.69 / $753.75 / $1,260.57
| Professional | | $640.69 | $753.75 | $1,260.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $829.59 / $891.35 / $891.35
| Facility | | $829.59 | $891.35 | $891.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $650.69 / $1,192.38 / $1,291.32
| Professional | | $650.69 | $1,192.38 | $1,291.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $603.15 / $715.53 / $1,192.55
| Professional | | $603.15 | $715.53 | $1,192.55 |