- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $656.59 / $869.11 / $3,221.71
| Professional | | $656.59 | $869.11 | $3,221.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $987.98 / $987.98 / $987.98
| Facility | | $987.98 | $987.98 | $987.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $484.52 / $987.98 / $1,026.65
| Professional | | $484.52 | $987.98 | $1,026.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $489.43 / $672.97 / $987.98
| Facility | | $489.43 | $672.97 | $987.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $593.62 / $987.98 / $1,284.50
| Professional | | $593.62 | $987.98 | $1,284.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.35 / $1,009.47 / $1,122.46
| Professional | | $794.35 | $1,009.47 | $1,122.46 |