- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $758.58 / $758.58 / $1,288.25
| Facility | | $758.58 | $758.58 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $758.58 / $933.25
| Professional | | $741.31 | $758.58 | $933.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $794.33 / $794.33
| Facility | | $794.33 | $794.33 | $794.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $794.33 / $794.33
| Professional | | $794.33 | $794.33 | $794.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $758.58 / $794.33 / $3,890.45
| Facility | | $758.58 | $794.33 | $3,890.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $794.33 / $794.33
| Facility | | $794.33 | $794.33 | $794.33 |