- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $578.54 / $578.54 / $1,013.18
| Professional | | $578.54 | $578.54 | $1,013.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,129.96 / $1,129.96 / $1,129.96
| Facility | | $1,129.96 | $1,129.96 | $1,129.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,129.96 / $1,129.96 / $1,129.96
| Professional | | $1,129.96 | $1,129.96 | $1,129.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $930.44 / $930.44 / $1,411.33
| Facility | | $930.44 | $930.44 | $1,411.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $679.22 / $679.22 / $930.44
| Professional | | $679.22 | $679.22 | $930.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $521.74 / $769.67 / $889.53
| Professional | | $521.74 | $769.67 | $889.53 |