- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $644.35 / $644.35 / $1,128.42
| Professional | | $644.35 | $644.35 | $1,128.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.48 / $1,258.48 / $1,258.48
| Facility | | $1,258.48 | $1,258.48 | $1,258.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.48 / $1,258.48 / $1,258.48
| Professional | | $1,258.48 | $1,258.48 | $1,258.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $908.11 / $908.11 / $1,417.56
| Facility | | $908.11 | $908.11 | $1,417.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $662.92 / $662.92 / $1,279.24
| Professional | | $662.92 | $662.92 | $1,279.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $581.08 / $857.22 / $990.71
| Professional | | $581.08 | $857.22 | $990.71 |