- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $519.71 / $686.16 / $2,655.14
| Professional | | $519.71 | $686.16 | $2,655.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $820.25 / $820.25 / $820.25
| Facility | | $820.25 | $820.25 | $820.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $435.03 / $820.25 / $854.96
| Professional | | $435.03 | $820.25 | $854.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $405.70 / $557.83 / $820.25
| Facility | | $405.70 | $557.83 | $820.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $499.48 / $820.25 / $1,080.80
| Professional | | $499.48 | $820.25 | $1,080.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $659.50 / $823.49 / $942.45
| Professional | | $659.50 | $823.49 | $942.45 |