- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $743.62 / $980.92 / $3,645.96
| Professional | | $743.62 | $980.92 | $3,645.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,114.70 / $1,114.70 / $1,114.70
| Facility | | $1,114.70 | $1,114.70 | $1,114.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $579.33 / $1,114.70 / $1,166.33
| Professional | | $579.33 | $1,114.70 | $1,166.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $552.16 / $759.23 / $1,114.70
| Facility | | $552.16 | $759.23 | $1,114.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $671.59 / $1,114.70 / $1,453.20
| Professional | | $671.59 | $1,114.70 | $1,453.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $943.29 / $1,143.19 / $1,284.48
| Professional | | $943.29 | $1,143.19 | $1,284.48 |