- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $759.95 / $825.53 / $1,177.66
| Professional | | $759.95 | $825.53 | $1,177.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,203.91 / $1,416.36 / $1,416.36
| Professional | | $1,203.91 | $1,416.36 | $1,416.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,208.78 / $1,208.78 / $1,208.78
| Facility | | $1,208.78 | $1,208.78 | $1,208.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,027.46 / $1,208.78 / $1,208.78
| Professional | | $1,027.46 | $1,208.78 | $1,208.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $880.57 / $1,189.80 / $1,983.00
| Professional | | $880.57 | $1,189.80 | $1,983.00 |