- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $759.95 / $1,133.08 / $1,517.53
| Professional | | $759.95 | $1,133.08 | $1,517.53 |
- 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 / $1,245.04
| Professional | | $1,027.46 | $1,208.78 | $1,245.04 |
- 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
- $1,208.78 / $1,208.78 / $1,245.04
| Professional | | $1,208.78 | $1,208.78 | $1,245.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $762.20 / $1,450.22 / $2,025.40
| Professional | | $762.20 | $1,450.22 | $2,025.40 |