- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $677.53 / $730.67 / $3,577.13
| Professional | | $677.53 | $730.67 | $3,577.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,093.66 / $1,093.66 / $1,093.66
| Facility | | $1,093.66 | $1,093.66 | $1,093.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $565.55 / $1,093.66 / $1,143.63
| Professional | | $565.55 | $1,093.66 | $1,143.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $542.34 / $743.92 / $1,093.66
| Facility | | $542.34 | $743.92 | $1,093.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $659.62 / $1,093.66 / $1,427.30
| Professional | | $659.62 | $1,093.66 | $1,427.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $888.43 / $1,103.21 / $1,260.81
| Professional | | $888.43 | $1,103.21 | $1,260.81 |