- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $994.58 / $1,065.73 / $1,065.73
| Professional | | $994.58 | $1,065.73 | $1,065.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,469.61 / $1,469.61 / $1,469.61
| Facility | | $1,469.61 | $1,469.61 | $1,469.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,249.17 / $1,322.65 / $1,469.61
| Professional | | $1,249.17 | $1,322.65 | $1,469.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $593.08 / $593.08 / $1,469.61
| Facility | | $593.08 | $593.08 | $1,469.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,249.17 / $1,469.61 / $2,049.98
| Professional | | $1,249.17 | $1,469.61 | $2,049.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,413.21 / $1,607.17 / $1,773.44
| Professional | | $1,413.21 | $1,607.17 | $1,773.44 |