- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $782.68 / $782.68 / $1,370.67
| Professional | | $782.68 | $782.68 | $1,370.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,528.66 / $1,528.66 / $1,528.66
| Facility | | $1,528.66 | $1,528.66 | $1,528.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,528.66 / $1,528.66 / $1,528.66
| Professional | | $1,528.66 | $1,528.66 | $1,528.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $926.75 / $926.75 / $1,684.23
| Facility | | $926.75 | $926.75 | $1,684.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $787.74 / $787.74 / $1,472.31
| Professional | | $787.74 | $787.74 | $1,472.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $668.75 / $739.92 / $1,140.19
| Professional | | $668.75 | $739.92 | $1,140.19 |