- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $743.26 / $981.05 / $3,643.57
| Professional | | $743.26 | $981.05 | $3,643.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,114.70 / $1,114.70 / $1,114.70
| Facility | | $1,114.70 | $1,114.70 | $1,114.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $578.53 / $1,114.70 / $1,165.75
| Professional | | $578.53 | $1,114.70 | $1,165.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $552.69 / $759.95 / $1,114.70
| Facility | | $552.69 | $759.95 | $1,114.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $671.26 / $1,114.70 / $1,452.50
| Professional | | $671.26 | $1,114.70 | $1,452.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $942.35 / $1,142.84 / $1,283.20
| Professional | | $942.35 | $1,142.84 | $1,283.20 |