- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $898.31 / $898.31 / $1,036.52
| Professional | | $898.31 | $898.31 | $1,036.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,329.56 / $1,329.56 / $1,329.56
| Facility | | $1,329.56 | $1,329.56 | $1,329.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $970.58 / $970.58 / $970.58
| Professional | | $970.58 | $970.58 | $970.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,329.56 / $1,329.56 / $1,329.56
| Facility | | $1,329.56 | $1,329.56 | $1,329.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $970.58 / $970.58 / $970.58
| Professional | | $970.58 | $970.58 | $970.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $829.21 / $1,466.74 / $1,530.63
| Professional | | $829.21 | $1,466.74 | $1,530.63 |