- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.77 / $602.77 / $1,055.60
| Professional | | $602.77 | $602.77 | $1,055.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,177.28 / $1,177.28 / $1,177.28
| Facility | | $1,177.28 | $1,177.28 | $1,177.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,177.28 / $1,177.28 / $1,177.28
| Professional | | $1,177.28 | $1,177.28 | $1,177.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $875.29 / $875.29 / $1,424.89
| Facility | | $875.29 | $875.29 | $1,424.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $638.96 / $638.96 / $875.29
| Professional | | $638.96 | $638.96 | $875.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $488.63 / $720.84 / $833.09
| Professional | | $488.63 | $720.84 | $833.09 |