- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $563.50 / $694.94 / $764.91
| Professional | | $563.50 | $694.94 | $764.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,823.42 / $2,462.75 / $2,915.60
| Facility | | $1,823.42 | $2,462.75 | $2,915.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $576.10 / $677.77 / $1,133.50
| Professional | | $576.10 | $677.77 | $1,133.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $745.98 / $930.44 / $930.44
| Facility | | $745.98 | $930.44 | $930.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $679.22 / $930.44 / $930.44
| Professional | | $679.22 | $930.44 | $930.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $581.53 / $821.95 / $1,072.33
| Professional | | $581.53 | $821.95 | $1,072.33 |