- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $595.38 / $595.38 / $1,042.66
| Professional | | $595.38 | $595.38 | $1,042.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,162.83 / $1,162.83 / $1,162.83
| Facility | | $1,162.83 | $1,162.83 | $1,162.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,162.83 / $1,162.83 / $1,162.83
| Professional | | $1,162.83 | $1,162.83 | $1,162.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $957.73 / $957.73 / $1,335.64
| Facility | | $957.73 | $957.73 | $1,335.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $699.14 / $699.14 / $957.73
| Professional | | $699.14 | $699.14 | $957.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $493.21 / $545.71 / $840.91
| Professional | | $493.21 | $545.71 | $840.91 |