- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $926.64 / $926.64 / $1,750.32
| Professional | | $926.64 | $926.64 | $1,750.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,799.29 / $1,799.29 / $1,799.29
| Professional | | $1,799.29 | $1,799.29 | $1,799.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,217.05 / $1,217.05 / $2,487.67
| Facility | | $1,217.05 | $1,217.05 | $2,487.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,217.05 / $1,217.05 / $1,217.05
| Professional | | $1,217.05 | $1,217.05 | $1,217.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $902.07 / $984.07 / $1,603.29
| Professional | | $902.07 | $984.07 | $1,603.29 |