- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $929.45 / $929.45 / $1,072.44
| Professional | | $929.45 | $929.45 | $1,072.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,551.30 / $1,551.30 / $1,551.30
| Facility | | $1,551.30 | $1,551.30 | $1,551.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,132.45 / $1,132.45 / $1,597.84
| Professional | | $1,132.45 | $1,132.45 | $1,597.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,551.30 / $1,551.30 / $1,551.30
| Facility | | $1,551.30 | $1,551.30 | $1,551.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,132.45 / $1,551.30 / $1,597.84
| Professional | | $1,132.45 | $1,551.30 | $1,597.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $633.47 / $1,431.35 / $2,201.86
| Professional | | $633.47 | $1,431.35 | $2,201.86 |