- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $728.93 / $728.93 / $1,276.55
| Professional | | $728.93 | $728.93 | $1,276.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,423.68 / $1,423.68 / $1,423.68
| Facility | | $1,423.68 | $1,423.68 | $1,423.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,423.68 / $1,423.68 / $1,423.68
| Professional | | $1,423.68 | $1,423.68 | $1,423.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $719.79 / $719.79 / $1,603.64
| Facility | | $719.79 | $719.79 | $1,603.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $525.45 / $525.45 / $719.79
| Professional | | $525.45 | $525.45 | $719.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $493.01 / $545.48 / $840.57
| Professional | | $493.01 | $545.48 | $840.57 |