- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $680.50 / $680.50 / $1,191.73
| Professional | | $680.50 | $680.50 | $1,191.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,329.09 / $1,329.09 / $1,329.09
| Facility | | $1,329.09 | $1,329.09 | $1,329.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,329.09 / $1,329.09 / $1,329.09
| Professional | | $1,329.09 | $1,329.09 | $1,329.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $660.31 / $660.31 / $1,122.81
| Facility | | $660.31 | $660.31 | $1,122.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $482.03 / $482.03 / $660.31
| Professional | | $482.03 | $482.03 | $660.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $460.25 / $509.24 / $784.72
| Professional | | $460.25 | $509.24 | $784.72 |