- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $553.60 / $696.50 / $751.47
| Professional | | $553.60 | $696.50 | $751.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,791.40 / $2,419.53 / $2,864.44
| Facility | | $1,791.40 | $2,419.53 | $2,864.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $703.43 / $827.57 / $1,145.79
| Professional | | $703.43 | $827.57 | $1,145.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $724.63 / $724.63 / $724.63
| Facility | | $724.63 | $724.63 | $724.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $528.98 / $724.63 / $724.63
| Professional | | $528.98 | $724.63 | $724.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $571.30 / $807.63 / $1,053.51
| Professional | | $571.30 | $807.63 | $1,053.51 |