- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $594.82 / $703.35 / $2,942.08
| Professional | | $594.82 | $703.35 | $2,942.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $882.82 / $882.82 / $882.82
| Facility | | $882.82 | $882.82 | $882.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $631.05 / $882.82 / $927.71
| Professional | | $631.05 | $882.82 | $927.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $436.41 / $1,034.15 / $1,063.86
| Facility | | $436.41 | $1,034.15 | $1,063.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $529.25 / $793.95 / $1,145.20
| Professional | | $529.25 | $793.95 | $1,145.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $836.16 / $964.80 / $1,529.94
| Professional | | $836.16 | $964.80 | $1,529.94 |