- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $857.68 / $857.68 / $1,502.02
| Professional | | $857.68 | $857.68 | $1,502.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,675.15 / $1,675.15 / $1,675.15
| Facility | | $1,675.15 | $1,675.15 | $1,675.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,675.15 / $1,675.15 / $1,675.15
| Professional | | $1,675.15 | $1,675.15 | $1,675.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,260.83 / $1,260.83 / $1,945.74
| Facility | | $1,260.83 | $1,260.83 | $1,945.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $920.41 / $920.41 / $1,260.83
| Professional | | $920.41 | $920.41 | $1,260.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $696.01 / $1,026.78 / $1,186.67
| Professional | | $696.01 | $1,026.78 | $1,186.67 |