- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $950.06 / $950.06 / $1,096.22
| Professional | | $950.06 | $950.06 | $1,096.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,430.94 / $1,576.65 / $1,576.65
| Facility | | $1,430.94 | $1,576.65 | $1,576.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,150.95 / $1,523.56 / $1,623.95
| Professional | | $1,150.95 | $1,523.56 | $1,623.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,430.94 / $1,576.65 / $1,576.65
| Facility | | $1,430.94 | $1,576.65 | $1,576.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,150.95 / $1,576.65 / $1,623.95
| Professional | | $1,150.95 | $1,576.65 | $1,623.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $647.52 / $1,410.27 / $2,250.69
| Professional | | $647.52 | $1,410.27 | $2,250.69 |