- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $582.87 / $582.87 / $1,020.75
| Professional | | $582.87 | $582.87 | $1,020.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,138.41 / $1,138.41 / $1,138.41
| Facility | | $1,138.41 | $1,138.41 | $1,138.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,138.41 / $1,138.41 / $1,138.41
| Professional | | $1,138.41 | $1,138.41 | $1,138.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $596.58 / $596.58 / $1,400.30
| Facility | | $596.58 | $596.58 | $1,400.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $435.50 / $435.50 / $947.70
| Professional | | $435.50 | $435.50 | $947.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $359.65 / $629.41 / $629.41
| Facility | | $359.65 | $629.41 | $629.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $430.49 / $635.08 / $733.98
| Professional | | $430.49 | $635.08 | $733.98 |