- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $657.14 / $657.14 / $1,228.74
| Facility | | $657.14 | $657.14 | $1,228.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $634.51 / $657.14 / $823.33
| Professional | | $634.51 | $657.14 | $823.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $665.68 / $948.89 / $2,329.33
| Facility | | $665.68 | $948.89 | $2,329.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $416.30 / $520.38 / $992.00
| Professional | | $416.30 | $520.38 | $992.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,003.84 / $1,003.84 / $1,003.84
| Facility | | $1,003.84 | $1,003.84 | $1,003.84 |