- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $828.40 / $828.40 / $1,035.50
| Professional | | $828.40 | $828.40 | $1,035.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,221.85 / $1,221.85 / $1,221.85
| Facility | | $1,221.85 | $1,221.85 | $1,221.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $523.13 / $1,230.41 / $2,010.38
| Professional | | $523.13 | $1,230.41 | $2,010.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $523.13 / $732.39 / $949.17
| Facility | | $523.13 | $732.39 | $949.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $523.13 / $949.17 / $1,230.41
| Professional | | $523.13 | $949.17 | $1,230.41 |