- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $999.54 / $3,466.84 / $3,466.84
| Professional | | $999.54 | $3,466.84 | $3,466.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $895.43 / $1,267.11 / $1,267.11
| Facility | | $895.43 | $1,267.11 | $1,267.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $895.43 / $1,030.44 / $1,267.11
| Professional | | $895.43 | $1,030.44 | $1,267.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $621.60 / $1,206.78 / $1,267.11
| Facility | | $621.60 | $1,206.78 | $1,267.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $895.43 / $951.04 / $1,268.05
| Professional | | $895.43 | $951.04 | $1,268.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $502.73 / $556.23 / $857.13
| Professional | | $502.73 | $556.23 | $857.13 |