- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $1,047.13 / $1,288.25
| Professional | | $707.95 | $1,047.13 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,047.13 / $1,047.13
| Professional | | $1,047.13 | $1,047.13 | $1,047.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,122.02 / $1,445.44
| Facility | | $1,122.02 | $1,122.02 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,122.02 / $1,995.26
| Professional | | $954.99 | $1,122.02 | $1,995.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $72.44 / $588.84 / $1,023.29
| Facility | | $72.44 | $588.84 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $870.96 / $1,348.96
| Professional | | $549.54 | $870.96 | $1,348.96 |