- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $601.70 / $601.70 / $815.91
| Professional | | $601.70 | $601.70 | $815.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $888.38 / $888.38 / $888.38
| Facility | | $888.38 | $888.38 | $888.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $648.52 / $648.52 / $888.38
| Professional | | $648.52 | $648.52 | $888.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,462.04 / $1,462.04 / $1,462.04
| Professional | | $1,462.04 | $1,462.04 | $1,462.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $567.63 / $729.40 / $1,048.42
| Professional | | $567.63 | $729.40 | $1,048.42 |