- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $895.57 / $895.57 / $1,033.34
| Professional | | $895.57 | $895.57 | $1,033.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,316.65 / $1,316.65 / $1,348.86
| Facility | | $1,316.65 | $1,316.65 | $1,348.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $961.15 / $1,316.65 / $1,356.15
| Professional | | $961.15 | $1,316.65 | $1,356.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,316.65 / $1,316.65 / $1,348.86
| Facility | | $1,316.65 | $1,316.65 | $1,348.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $961.15 / $1,316.65 / $1,356.15
| Professional | | $961.15 | $1,316.65 | $1,356.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $634.79 / $1,379.18 / $2,121.61
| Professional | | $634.79 | $1,379.18 | $2,121.61 |