- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $543.20 / $543.20 / $1,235.90
| Professional | | $543.20 | $543.20 | $1,235.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,054.70 / $1,054.70 / $1,054.70
| Professional | | $1,054.70 | $1,054.70 | $1,054.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $816.59 / $816.59 / $904.08
| Facility | | $816.59 | $816.59 | $904.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $816.59 / $816.59 / $816.59
| Professional | | $816.59 | $816.59 | $816.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $506.05 / $598.58 / $1,039.80
| Professional | | $506.05 | $598.58 | $1,039.80 |