- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $840.72 / $840.72 / $970.07
| Professional | | $840.72 | $840.72 | $970.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,266.25 / $1,324.18 / $1,324.18
| Facility | | $1,266.25 | $1,324.18 | $1,324.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $966.65 / $1,305.65 / $1,363.91
| Professional | | $966.65 | $1,305.65 | $1,363.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,266.25 / $1,324.18 / $1,324.18
| Facility | | $1,266.25 | $1,324.18 | $1,324.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $966.65 / $1,324.18 / $1,363.91
| Professional | | $966.65 | $1,324.18 | $1,363.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $640.00 / $640.00 / $640.00
| Facility | | $640.00 | $640.00 | $640.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $573.00 / $1,241.69 / $1,991.67
| Professional | | $573.00 | $1,241.69 | $1,991.67 |