- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $670.95 / $908.12 / $3,403.63
| Professional | | $670.95 | $908.12 | $3,403.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,015.85 / $1,015.85 / $1,015.85
| Facility | | $1,015.85 | $1,015.85 | $1,015.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.60 / $1,015.85 / $1,077.28
| Professional | | $549.60 | $1,015.85 | $1,077.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $508.30 / $698.92 / $1,015.85
| Facility | | $508.30 | $698.92 | $1,015.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $613.03 / $1,015.85 / $1,329.63
| Professional | | $613.03 | $1,015.85 | $1,329.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $868.56 / $1,042.75 / $1,182.72
| Professional | | $868.56 | $1,042.75 | $1,182.72 |