- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $716.53 / $716.53 / $826.76
| Professional | | $716.53 | $716.53 | $826.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,038.85 / $1,038.85 / $1,079.19
| Facility | | $1,038.85 | $1,038.85 | $1,079.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.37 / $836.96 / $1,107.48
| Professional | | $758.37 | $836.96 | $1,107.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,038.85 / $1,038.85 / $1,079.19
| Facility | | $1,038.85 | $1,038.85 | $1,079.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.37 / $1,038.85 / $1,107.48
| Professional | | $758.37 | $1,038.85 | $1,107.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $488.35 / $869.78 / $1,697.45
| Professional | | $488.35 | $869.78 | $1,697.45 |