- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $583.19 / $583.19 / $1,021.31
| Professional | | $583.19 | $583.19 | $1,021.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,139.03 / $1,139.03 / $1,139.03
| Facility | | $1,139.03 | $1,139.03 | $1,139.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,139.03 / $1,139.03 / $1,139.03
| Professional | | $1,139.03 | $1,139.03 | $1,139.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $673.11 / $673.11 / $1,080.18
| Facility | | $673.11 | $673.11 | $1,080.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $491.37 / $491.37 / $673.11
| Professional | | $491.37 | $491.37 | $673.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $394.45 / $436.42 / $672.51
| Professional | | $394.45 | $436.42 | $672.51 |