- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $539.15 / $539.15 / $944.20
| Professional | | $539.15 | $539.15 | $944.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,053.03 / $1,053.03 / $1,053.03
| Facility | | $1,053.03 | $1,053.03 | $1,053.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,053.03 / $1,053.03 / $1,053.03
| Professional | | $1,053.03 | $1,053.03 | $1,053.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $649.92 / $649.92 / $918.16
| Facility | | $649.92 | $649.92 | $918.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $474.45 / $474.45 / $649.92
| Professional | | $474.45 | $474.45 | $649.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $364.66 / $537.95 / $621.73
| Professional | | $364.66 | $537.95 | $621.73 |