- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $801.52 / $801.52 / $1,403.68
| Professional | | $801.52 | $801.52 | $1,403.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,565.47 / $1,565.47 / $1,565.47
| Facility | | $1,565.47 | $1,565.47 | $1,565.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,565.47 / $1,565.47 / $1,565.47
| Professional | | $1,565.47 | $1,565.47 | $1,565.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $913.06 / $913.06 / $1,861.20
| Facility | | $913.06 | $913.06 | $1,861.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $666.53 / $666.53 / $913.06
| Professional | | $666.53 | $666.53 | $913.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $658.87 / $844.12 / $1,123.34
| Professional | | $658.87 | $844.12 | $1,123.34 |