- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $714.68 / $714.68 / $824.63
| Professional | | $714.68 | $714.68 | $824.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,036.33 / $1,036.33 / $1,076.41
| Facility | | $1,036.33 | $1,036.33 | $1,076.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $756.53 / $893.06 / $1,067.43
| Professional | | $756.53 | $893.06 | $1,067.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,036.33 / $1,036.33 / $1,076.41
| Facility | | $1,036.33 | $1,036.33 | $1,076.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $756.53 / $1,036.33 / $1,067.43
| Professional | | $756.53 | $1,036.33 | $1,067.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $487.09 / $1,032.93 / $1,693.06
| Professional | | $487.09 | $1,032.93 | $1,693.06 |