- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $570.84 / $756.81 / $2,796.32
| Professional | | $570.84 | $756.81 | $2,796.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $860.21 / $860.21 / $860.21
| Facility | | $860.21 | $860.21 | $860.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $440.96 / $860.21 / $886.97
| Professional | | $440.96 | $860.21 | $886.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $426.70 / $586.72 / $860.21
| Facility | | $426.70 | $586.72 | $860.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $516.63 / $860.21 / $1,117.90
| Professional | | $516.63 | $860.21 | $1,117.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $720.50 / $869.75 / $981.11
| Professional | | $720.50 | $869.75 | $981.11 |