- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $764.63 / $764.63 / $1,339.07
| Professional | | $764.63 | $764.63 | $1,339.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,493.41 / $1,493.41 / $1,493.41
| Facility | | $1,493.41 | $1,493.41 | $1,493.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,493.41 / $1,493.41 / $1,493.41
| Professional | | $1,493.41 | $1,493.41 | $1,493.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $843.35 / $843.35 / $1,650.68
| Facility | | $843.35 | $843.35 | $1,650.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $716.85 / $716.85 / $843.35
| Professional | | $716.85 | $716.85 | $843.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $608.57 / $673.33 / $1,037.58
| Professional | | $608.57 | $673.33 | $1,037.58 |