- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $837.76 / $837.76 / $966.65
| Professional | | $837.76 | $837.76 | $966.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,261.79 / $1,473.53 / $1,473.53
| Facility | | $1,261.79 | $1,473.53 | $1,473.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,069.02 / $1,358.34 / $1,517.74
| Professional | | $1,069.02 | $1,358.34 | $1,517.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,261.79 / $1,473.53 / $1,473.53
| Facility | | $1,261.79 | $1,473.53 | $1,473.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,069.02 / $1,473.53 / $1,517.74
| Professional | | $1,069.02 | $1,473.53 | $1,517.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $593.82 / $1,290.15 / $1,984.65
| Professional | | $593.82 | $1,290.15 | $1,984.65 |