- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $671.48 / $692.26 / $911.49
| Professional | | $671.48 | $692.26 | $911.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,172.85 / $2,934.73 / $3,474.38
| Facility | | $2,172.85 | $2,934.73 | $3,474.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $686.50 / $807.65 / $1,350.73
| Professional | | $686.50 | $807.65 | $1,350.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.21 / $812.21 / $888.94
| Facility | | $812.21 | $812.21 | $888.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $592.91 / $812.21 / $812.21
| Professional | | $592.91 | $812.21 | $812.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $692.96 / $864.14 / $1,277.83
| Professional | | $692.96 | $864.14 | $1,277.83 |