- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $836.02 / $836.02 / $964.64
| Professional | | $836.02 | $836.02 | $964.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,232.20 / $1,232.20 / $1,259.18
| Facility | | $1,232.20 | $1,232.20 | $1,259.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $899.51 / $930.57 / $1,313.59
| Professional | | $899.51 | $930.57 | $1,313.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,232.20 / $1,232.20 / $1,259.18
| Facility | | $1,232.20 | $1,232.20 | $1,259.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $899.51 / $1,232.20 / $1,313.59
| Professional | | $899.51 | $1,232.20 | $1,313.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $569.79 / $1,287.48 / $1,980.54
| Professional | | $569.79 | $1,287.48 | $1,980.54 |