- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $859.94 / $859.94 / $992.24
| Professional | | $859.94 | $859.94 | $992.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,295.21 / $1,498.90 / $1,498.90
| Facility | | $1,295.21 | $1,498.90 | $1,498.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,094.20 / $1,394.30 / $1,543.87
| Professional | | $1,094.20 | $1,394.30 | $1,543.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,295.21 / $1,498.90 / $1,498.90
| Facility | | $1,295.21 | $1,498.90 | $1,498.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,094.20 / $1,498.90 / $1,543.87
| Professional | | $1,094.20 | $1,498.90 | $1,543.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $793.79 / $1,404.08 / $1,465.24
| Professional | | $793.79 | $1,404.08 | $1,465.24 |