- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.54 / $635.70 / $3,117.78
| Professional | | $575.54 | $635.70 | $3,117.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $958.53 / $958.53 / $958.53
| Facility | | $958.53 | $958.53 | $958.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $518.22 / $958.53 / $1,001.62
| Professional | | $518.22 | $958.53 | $1,001.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $475.25 / $653.47 / $958.53
| Facility | | $475.25 | $653.47 | $958.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.17 / $958.53 / $1,244.59
| Professional | | $575.17 | $958.53 | $1,244.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $872.61 / $992.37 / $1,234.98
| Professional | | $872.61 | $992.37 | $1,234.98 |