- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $836.47 / $836.47 / $1,032.19
| Professional | | $836.47 | $836.47 | $1,032.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,499.77 / $1,499.77 / $1,499.77
| Facility | | $1,499.77 | $1,499.77 | $1,499.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,579.40 / $1,579.40 / $1,579.40
| Facility | | $1,579.40 | $1,579.40 | $1,579.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $360.74 / $360.74 / $820.58
| Professional | | $360.74 | $360.74 | $820.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,579.40 / $1,579.40 / $1,579.40
| Facility | | $1,579.40 | $1,579.40 | $1,579.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $360.74 / $360.74 / $820.58
| Professional | | $360.74 | $360.74 | $820.58 |