- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $983.41 / $983.41 / $1,134.71
| Professional | | $983.41 | $983.41 | $1,134.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,335.63 / $1,335.63 / $1,335.63
| Facility | | $1,335.63 | $1,335.63 | $1,335.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $975.01 / $975.01 / $1,375.70
| Professional | | $975.01 | $975.01 | $1,375.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,335.63 / $1,335.63 / $1,335.63
| Facility | | $1,335.63 | $1,335.63 | $1,335.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $975.01 / $1,335.63 / $1,375.70
| Professional | | $975.01 | $1,335.63 | $1,375.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $670.25 / $1,193.75 / $2,329.69
| Professional | | $670.25 | $1,193.75 | $2,329.69 |