- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $657.33 / $2,279.96 / $2,279.96
| Professional | | $657.33 | $2,279.96 | $2,279.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $589.44 / $1,106.29 / $1,106.29
| Facility | | $589.44 | $1,106.29 | $1,106.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $589.44 / $899.65 / $1,106.29
| Professional | | $589.44 | $899.65 | $1,106.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $440.56 / $1,053.60 / $1,106.29
| Facility | | $440.56 | $1,053.60 | $1,106.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $589.44 / $830.32 / $1,107.09
| Professional | | $589.44 | $830.32 | $1,107.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $356.31 / $394.23 / $625.24
| Professional | | $356.31 | $394.23 | $625.24 |