- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $620.84 / $625.29 / $625.29
| Professional | | $620.84 | $625.29 | $625.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,020.05 / $1,020.05 / $1,020.05
| Facility | | $1,020.05 | $1,020.05 | $1,020.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $810.48 / $1,020.05 / $1,020.05
| Professional | | $810.48 | $1,020.05 | $1,020.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $501.24 / $626.54 / $1,020.05
| Facility | | $501.24 | $626.54 | $1,020.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $581.65 / $872.57 / $1,258.59
| Professional | | $581.65 | $872.57 | $1,258.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $916.97 / $1,060.82 / $1,786.17
| Professional | | $916.97 | $1,060.82 | $1,786.17 |