- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $736.66 / $736.66 / $1,151.86
| Professional | | $736.66 | $736.66 | $1,151.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,284.63 / $1,284.63 / $1,284.63
| Facility | | $1,284.63 | $1,284.63 | $1,284.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,284.63 / $1,284.63 / $1,284.63
| Professional | | $1,284.63 | $1,284.63 | $1,284.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $830.86 / $830.86 / $1,447.01
| Facility | | $830.86 | $830.86 | $1,447.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $606.53 / $606.53 / $830.86
| Professional | | $606.53 | $606.53 | $830.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $593.15 / $656.27 / $728.59
| Professional | | $593.15 | $656.27 | $728.59 |