- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $608.48 / $806.07 / $2,983.62
| Professional | | $608.48 | $806.07 | $2,983.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $918.05 / $918.05 / $918.05
| Facility | | $918.05 | $918.05 | $918.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $469.58 / $918.05 / $948.08
| Professional | | $469.58 | $918.05 | $948.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $454.84 / $625.41 / $918.05
| Facility | | $454.84 | $625.41 | $918.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $550.60 / $917.72 / $1,191.40
| Professional | | $550.60 | $917.72 | $1,191.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $730.83 / $917.12 / $1,047.68
| Professional | | $730.83 | $917.12 | $1,047.68 |