- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $831.76 / $1,380.38
| Professional | | $630.96 | $831.76 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,096.48 / $1,096.48
| Professional | | $1,096.48 | $1,096.48 | $1,096.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,096.48 / $2,511.89
| Facility | | $1,096.48 | $1,096.48 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $812.83 / $1,995.26
| Professional | | $812.83 | $812.83 | $1,995.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $912.01 / $1,047.13 / $1,862.09
| Facility | | $912.01 | $1,047.13 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $691.83 / $1,047.13
| Professional | | $457.09 | $691.83 | $1,047.13 |