- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $866.13 / $866.13 / $999.38
| Professional | | $866.13 | $866.13 | $999.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,030.36 / $1,030.36 / $1,030.36
| Facility | | $1,030.36 | $1,030.36 | $1,030.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $752.17 / $752.17 / $1,325.59
| Professional | | $752.17 | $752.17 | $1,325.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,030.36 / $1,030.36 / $1,030.36
| Facility | | $1,030.36 | $1,030.36 | $1,030.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $752.17 / $752.17 / $1,325.59
| Professional | | $752.17 | $752.17 | $1,325.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $613.92 / $1,051.38 / $2,051.86
| Professional | | $613.92 | $1,051.38 | $2,051.86 |