- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $642.25 / $871.80 / $956.81
| Professional | | $642.25 | $871.80 | $956.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,078.27 / $2,806.97 / $3,323.11
| Facility | | $2,078.27 | $2,806.97 | $3,323.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $816.08 / $960.09 / $1,329.26
| Professional | | $816.08 | $960.09 | $1,329.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $850.23 / $913.06 / $913.06
| Facility | | $850.23 | $913.06 | $913.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $666.53 / $913.06 / $913.06
| Professional | | $666.53 | $913.06 | $913.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $690.28 / $898.68 / $1,222.21
| Professional | | $690.28 | $898.68 | $1,222.21 |