- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $711.43 / $934.71 / $3,485.30
| Professional | | $711.43 | $934.71 | $3,485.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,064.75 / $1,064.75 / $1,064.75
| Facility | | $1,064.75 | $1,064.75 | $1,064.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $556.30 / $1,064.75 / $1,120.34
| Professional | | $556.30 | $1,064.75 | $1,120.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $527.84 / $725.78 / $1,064.75
| Facility | | $527.84 | $725.78 | $1,064.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $641.50 / $1,064.75 / $1,388.10
| Professional | | $641.50 | $1,064.75 | $1,388.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $904.27 / $1,096.67 / $1,231.34
| Professional | | $904.27 | $1,096.67 | $1,231.34 |