- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $953.37 / $953.37 / $1,669.60
| Professional | | $953.37 | $953.37 | $1,669.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,862.05 / $1,862.05 / $1,862.05
| Facility | | $1,862.05 | $1,862.05 | $1,862.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.05 / $1,862.05 / $1,862.05
| Professional | | $1,862.05 | $1,862.05 | $1,862.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,329.56 / $1,329.56 / $2,064.41
| Facility | | $1,329.56 | $1,329.56 | $2,064.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $970.58 / $970.58 / $1,672.70
| Professional | | $970.58 | $970.58 | $1,672.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $759.70 / $1,120.74 / $1,295.26
| Professional | | $759.70 | $1,120.74 | $1,295.26 |