- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $603.39 / $603.39 / $1,056.71
| Professional | | $603.39 | $603.39 | $1,056.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,178.50 / $1,178.50 / $1,178.50
| Facility | | $1,178.50 | $1,178.50 | $1,178.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,178.50 / $1,178.50 / $1,178.50
| Professional | | $1,178.50 | $1,178.50 | $1,178.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $895.43 / $895.43 / $1,347.58
| Facility | | $895.43 | $895.43 | $1,347.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $653.66 / $653.66 / $895.43
| Professional | | $653.66 | $653.66 | $895.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $502.73 / $556.23 / $857.13
| Professional | | $502.73 | $556.23 | $857.13 |