- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $689.74 / $689.74 / $1,207.91
| Professional | | $689.74 | $689.74 | $1,207.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,347.14 / $1,347.14 / $1,347.14
| Facility | | $1,347.14 | $1,347.14 | $1,347.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,347.14 / $1,347.14 / $1,347.14
| Professional | | $1,347.14 | $1,347.14 | $1,347.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,036.33 / $1,036.33 / $2,015.44
| Facility | | $1,036.33 | $1,036.33 | $2,015.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $756.53 / $756.53 / $1,036.33
| Professional | | $756.53 | $756.53 | $1,036.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $619.61 / $914.08 / $1,056.42
| Professional | | $619.61 | $914.08 | $1,056.42 |