- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $666.75 / $789.52 / $3,870.46
| Professional | | $666.75 | $789.52 | $3,870.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,183.58 / $1,183.58 / $1,183.58
| Facility | | $1,183.58 | $1,183.58 | $1,183.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.66 / $1,183.58 / $1,240.82
| Professional | | $630.66 | $1,183.58 | $1,240.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $586.48 / $806.41 / $1,183.58
| Facility | | $586.48 | $806.41 | $1,183.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $712.67 / $1,183.58 / $1,542.10
| Professional | | $712.67 | $1,183.58 | $1,542.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,002.04 / $1,215.24 / $1,402.49
| Professional | | $1,002.04 | $1,215.24 | $1,402.49 |