- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $797.38 / $797.38 / $1,396.42
| Professional | | $797.38 | $797.38 | $1,396.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,557.38 / $1,557.38 / $1,557.38
| Facility | | $1,557.38 | $1,557.38 | $1,557.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,557.38 / $1,557.38 / $1,557.38
| Professional | | $1,557.38 | $1,557.38 | $1,557.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,020.64 / $1,020.64 / $2,274.12
| Facility | | $1,020.64 | $1,020.64 | $2,274.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $745.07 / $745.07 / $1,020.64
| Professional | | $745.07 | $745.07 | $1,020.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $719.08 / $795.61 / $1,226.00
| Professional | | $719.08 | $795.61 | $1,226.00 |