- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $750.36 / $988.68 / $3,675.74
| Professional | | $750.36 | $988.68 | $3,675.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,124.16 / $1,124.16 / $1,124.16
| Facility | | $1,124.16 | $1,124.16 | $1,124.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $594.20 / $1,124.16 / $1,176.22
| Professional | | $594.20 | $1,124.16 | $1,176.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $556.54 / $765.24 / $1,124.16
| Facility | | $556.54 | $765.24 | $1,124.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $677.41 / $1,124.16 / $1,465.80
| Professional | | $677.41 | $1,124.16 | $1,465.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $970.53 / $1,160.81 / $1,283.43
| Professional | | $970.53 | $1,160.81 | $1,283.43 |