- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $906.46 / $906.46 / $1,587.46
| Professional | | $906.46 | $906.46 | $1,587.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,770.43 / $1,770.43 / $1,770.43
| Facility | | $1,770.43 | $1,770.43 | $1,770.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,770.43 / $1,770.43 / $1,770.43
| Professional | | $1,770.43 | $1,770.43 | $1,770.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,132.82 / $1,132.82 / $2,608.30
| Facility | | $1,132.82 | $1,132.82 | $2,608.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $826.96 / $826.96 / $1,799.86
| Professional | | $826.96 | $826.96 | $1,799.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $817.45 / $1,205.93 / $1,393.73
| Professional | | $817.45 | $1,205.93 | $1,393.73 |