- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $812.83 / $1,071.52
| Professional | | $575.44 | $812.83 | $1,071.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $870.96 / $870.96 / $1,318.26
| Facility | | $870.96 | $870.96 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $630.96 / $891.25
| Professional | | $630.96 | $630.96 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,659.59 / $1,778.28
| Professional | | $1,412.54 | $1,659.59 | $1,778.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $891.25 / $1,513.56
| Facility | | $891.25 | $891.25 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $1,348.96 / $3,715.35
| Professional | | $616.60 | $1,348.96 | $3,715.35 |