- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $968.97 / $968.97 / $1,054.32
| Professional | | $968.97 | $968.97 | $1,054.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,113.25 / $1,113.25 / $1,113.25
| Facility | | $1,113.25 | $1,113.25 | $1,113.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,113.25 / $1,113.25 / $1,113.25
| Professional | | $1,113.25 | $1,113.25 | $1,113.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,276.54 / $1,276.54 / $1,276.54
| Facility | | $1,276.54 | $1,276.54 | $1,276.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $517.14 / $517.14 / $1,069.53
| Professional | | $517.14 | $517.14 | $1,069.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $485.80 / $537.49 / $596.72
| Professional | | $485.80 | $537.49 | $596.72 |