- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,423.50 / $1,674.60 / $1,850.40
| Professional | | $1,423.50 | $1,674.60 | $1,850.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $183.14 / $233.58 / $2,164.96
| Facility | | $183.14 | $233.58 | $2,164.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $183.14 / $251.55 / $2,331.50
| Professional | | $183.14 | $251.55 | $2,331.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $213.28 / $1,414.26 / $2,663.06
| Facility | | $213.28 | $1,414.26 | $2,663.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $199.14 / $1,414.26 / $2,023.29
| Professional | | $199.14 | $1,414.26 | $2,023.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,311.77 / $1,690.50 / $2,572.10
| Professional | | $1,311.77 | $1,690.50 | $2,572.10 |