- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $864.53 / $864.53 / $997.54
| Professional | | $864.53 | $864.53 | $997.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,107.01 / $1,107.01 / $1,302.13
| Facility | | $1,107.01 | $1,107.01 | $1,302.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $808.12 / $1,499.62 / $1,619.01
| Professional | | $808.12 | $1,499.62 | $1,619.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,107.01 / $1,107.01 / $1,302.13
| Facility | | $1,107.01 | $1,107.01 | $1,302.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,103.14 / $1,519.30 / $1,619.01
| Professional | | $1,103.14 | $1,519.30 | $1,619.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $589.23 / $1,049.45 / $2,048.08
| Professional | | $589.23 | $1,049.45 | $2,048.08 |