- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $957.26 / $957.26 / $957.26
| Professional | | $957.26 | $957.26 | $957.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,292.10 / $1,292.10 / $1,292.10
| Facility | | $1,292.10 | $1,292.10 | $1,292.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $887.12 / $887.12 / $1,108.91
| Professional | | $887.12 | $887.12 | $1,108.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,292.10 / $1,292.10 / $1,292.10
| Facility | | $1,292.10 | $1,292.10 | $1,292.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.79 / $887.12 / $1,108.91
| Professional | | $501.79 | $887.12 | $1,108.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $463.19 / $463.19 / $1,080.77
| Professional | | $463.19 | $463.19 | $1,080.77 |