- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.20 / $979.98 / $3,454.48
| Professional | | $724.20 | $979.98 | $3,454.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,084.20 / $1,084.20 / $1,084.20
| Facility | | $1,084.20 | $1,084.20 | $1,084.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $518.04 / $1,034.80 / $1,084.20
| Professional | | $518.04 | $1,034.80 | $1,084.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $528.86 / $727.18 / $1,084.20
| Facility | | $528.86 | $727.18 | $1,084.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $663.50 / $1,038.25 / $1,435.70
| Professional | | $663.50 | $1,038.25 | $1,435.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $639.42 / $1,023.55 / $1,191.04
| Professional | | $639.42 | $1,023.55 | $1,191.04 |