- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $540.58 / $640.57 / $3,140.64
| Professional | | $540.58 | $640.57 | $3,140.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $965.37 / $965.37 / $965.37
| Facility | | $965.37 | $965.37 | $965.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $510.09 / $965.37 / $1,003.01
| Professional | | $510.09 | $965.37 | $1,003.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $478.34 / $657.72 / $965.37
| Facility | | $478.34 | $657.72 | $965.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $579.39 / $965.37 / $1,253.70
| Professional | | $579.39 | $965.37 | $1,253.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $841.50 / $982.67 / $1,369.50
| Professional | | $841.50 | $982.67 | $1,369.50 |