- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $866.03 / $866.03 / $999.27
| Professional | | $866.03 | $866.03 | $999.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,304.38 / $1,530.70 / $1,530.70
| Facility | | $1,304.38 | $1,530.70 | $1,530.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,105.06 / $1,117.41 / $1,117.41
| Professional | | $1,105.06 | $1,117.41 | $1,117.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,304.38 / $1,530.70 / $1,530.70
| Facility | | $1,304.38 | $1,530.70 | $1,530.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,105.06 / $1,117.41 / $1,117.41
| Professional | | $1,105.06 | $1,117.41 | $1,117.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $590.25 / $1,333.69 / $2,051.63
| Professional | | $590.25 | $1,333.69 | $2,051.63 |