- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $597.66 / $597.66 / $1,046.68
| Professional | | $597.66 | $597.66 | $1,046.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,167.32 / $1,167.32 / $1,167.32
| Facility | | $1,167.32 | $1,167.32 | $1,167.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,167.32 / $1,167.32 / $1,167.32
| Professional | | $1,167.32 | $1,167.32 | $1,167.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $765.11 / $765.11 / $1,307.09
| Facility | | $765.11 | $765.11 | $1,307.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $558.53 / $558.53 / $765.11
| Professional | | $558.53 | $558.53 | $765.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $452.69 / $500.87 / $771.82
| Professional | | $452.69 | $500.87 | $771.82 |