- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.51 / $794.51 / $794.51
| Professional | | $794.51 | $794.51 | $794.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,072.41 / $1,072.41 / $1,072.41
| Facility | | $1,072.41 | $1,072.41 | $1,072.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $736.38 / $827.19 / $920.47
| Professional | | $736.38 | $827.19 | $920.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,072.41 / $1,072.41 / $1,072.41
| Facility | | $1,072.41 | $1,072.41 | $1,072.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $416.47 / $736.38 / $920.47
| Professional | | $416.47 | $736.38 | $920.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $384.44 / $384.44 / $897.02
| Professional | | $384.44 | $384.44 | $897.02 |