- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $760.96 / $760.96 / $951.20
| Professional | | $760.96 | $760.96 | $951.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,340.15 / $1,340.15 / $1,340.15
| Facility | | $1,340.15 | $1,340.15 | $1,340.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $486.00 / $1,769.44 / $1,769.44
| Professional | | $486.00 | $1,769.44 | $1,769.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $409.81 / $409.81 / $698.28
| Facility | | $409.81 | $409.81 | $698.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $409.81 / $675.37 / $733.74
| Professional | | $409.81 | $675.37 | $733.74 |