- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $843.74 / $843.74 / $973.55
| Professional | | $843.74 | $843.74 | $973.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,260.83 / $1,260.83 / $1,260.83
| Facility | | $1,260.83 | $1,260.83 | $1,260.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $920.41 / $920.41 / $1,344.11
| Professional | | $920.41 | $920.41 | $1,344.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,260.83 / $1,260.83 / $1,260.83
| Facility | | $1,260.83 | $1,260.83 | $1,260.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $920.41 / $1,260.83 / $1,344.11
| Professional | | $920.41 | $1,260.83 | $1,344.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.04 / $1,160.27 / $1,998.82
| Professional | | $575.04 | $1,160.27 | $1,998.82 |