- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $660.69 / $933.25
| Professional | | $512.86 | $660.69 | $933.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,047.13 / $1,047.13
| Facility | | $1,047.13 | $1,047.13 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,047.13 / $1,047.13
| Professional | | $1,047.13 | $1,047.13 | $1,047.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $776.25 / $776.25 / $1,174.90
| Facility | | $776.25 | $776.25 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $562.34 / $1,047.13
| Professional | | $562.34 | $562.34 | $1,047.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $389.05 / $512.86 / $851.14
| Facility | | $389.05 | $512.86 | $851.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.74 / $524.81 / $776.25
| Professional | | $467.74 | $524.81 | $776.25 |