- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $554.54 / $611.66 / $1,063.08
| Professional | | $554.54 | $611.66 | $1,063.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $553.49 / $553.49 / $1,198.44
| Facility | | $553.49 | $553.49 | $1,198.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $508.76 / $508.76 / $553.49
| Professional | | $508.76 | $508.76 | $553.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $553.49 / $553.49 / $1,198.44
| Facility | | $553.49 | $553.49 | $1,198.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $508.76 / $551.95 / $719.94
| Professional | | $508.76 | $551.95 | $719.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $508.76 / $508.76 / $508.76
| Professional | | $508.76 | $508.76 | $508.76 |