- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $897.13 / $897.13 / $1,571.10
| Professional | | $897.13 | $897.13 | $1,571.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,752.19 / $1,752.19 / $1,752.19
| Facility | | $1,752.19 | $1,752.19 | $1,752.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,752.19 / $1,752.19 / $1,752.19
| Professional | | $1,752.19 | $1,752.19 | $1,752.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $870.50 / $870.50 / $1,480.25
| Facility | | $870.50 | $870.50 | $1,480.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $635.47 / $635.47 / $870.50
| Professional | | $635.47 | $635.47 | $870.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $606.77 / $671.35 / $1,034.53
| Professional | | $606.77 | $671.35 | $1,034.53 |