- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $807.44 / $807.44 / $931.67
| Professional | | $807.44 | $807.44 | $931.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,216.13 / $1,427.14 / $1,427.14
| Facility | | $1,216.13 | $1,427.14 | $1,427.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,030.58 / $1,206.76 / $1,469.95
| Professional | | $1,030.58 | $1,206.76 | $1,469.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,216.13 / $1,427.14 / $1,427.14
| Facility | | $1,216.13 | $1,427.14 | $1,427.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,030.58 / $1,427.14 / $1,469.95
| Professional | | $1,030.58 | $1,427.14 | $1,469.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $550.32 / $1,243.74 / $1,375.79
| Professional | | $550.32 | $1,243.74 | $1,375.79 |