- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $892.66 / $1,217.33 / $4,328.27
| Professional | | $892.66 | $1,217.33 | $4,328.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,328.17 / $1,328.17 / $1,328.17
| Facility | | $1,328.17 | $1,328.17 | $1,328.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $678.27 / $1,328.17 / $1,332.20
| Professional | | $678.27 | $1,328.17 | $1,332.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $649.98 / $893.72 / $1,328.17
| Facility | | $649.98 | $893.72 | $1,328.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $816.84 / $1,328.17 / $1,767.50
| Professional | | $816.84 | $1,328.17 | $1,767.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.04 / $1,310.23 / $1,492.48
| Professional | | $1,096.04 | $1,310.23 | $1,492.48 |