- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $736.45 / $974.53 / $3,601.64
| Professional | | $736.45 | $974.53 | $3,601.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,107.85 / $1,107.85 / $1,107.85
| Facility | | $1,107.85 | $1,107.85 | $1,107.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $585.36 / $1,107.85 / $1,147.11
| Professional | | $585.36 | $1,107.85 | $1,147.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $549.86 / $756.06 / $1,107.85
| Facility | | $549.86 | $756.06 | $1,107.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $666.09 / $1,107.85 / $1,441.30
| Professional | | $666.09 | $1,107.85 | $1,441.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $870.05 / $870.05 / $6,489.22
| Facility | | $870.05 | $870.05 | $6,489.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $926.37 / $1,123.47 / $1,261.44
| Professional | | $926.37 | $1,123.47 | $1,261.44 |