- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $791.80 / $1,060.44 / $1,060.44
| Professional | | $791.80 | $1,060.44 | $1,060.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,116.58 / $1,116.58 / $1,116.58
| Facility | | $1,116.58 | $1,116.58 | $1,116.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $949.10 / $1,116.58 / $1,150.08
| Professional | | $949.10 | $1,116.58 | $1,150.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,116.58 / $1,116.58 / $1,116.58
| Facility | | $1,116.58 | $1,116.58 | $1,116.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,116.58 / $1,116.58 / $1,150.08
| Professional | | $1,116.58 | $1,116.58 | $1,150.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $572.85 / $1,329.32 / $1,476.74
| Professional | | $572.85 | $1,329.32 | $1,476.74 |