- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $966.75 / $1,283.65 / $4,840.56
| Professional | | $966.75 | $1,283.65 | $4,840.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.42 / $1,445.42 / $1,445.42
| Facility | | $1,445.42 | $1,445.42 | $1,445.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $746.56 / $1,445.42 / $1,472.46
| Professional | | $746.56 | $1,445.42 | $1,472.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $717.01 / $985.89 / $1,445.42
| Facility | | $717.01 | $985.89 | $1,445.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $875.07 / $1,445.42 / $1,893.50
| Professional | | $875.07 | $1,445.42 | $1,893.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,248.79 / $1,487.92 / $1,690.26
| Professional | | $1,248.79 | $1,487.92 | $1,690.26 |