- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $870.96 / $1,071.52
| Professional | | $870.96 | $870.96 | $1,071.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $954.99 / $2,187.76 / $2,398.83
| Facility | | $954.99 | $2,187.76 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $3,162.28 / $3,162.28
| Professional | | $1,148.15 | $3,162.28 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,187.76 / $2,187.76
| Professional | | $2,187.76 | $2,187.76 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $0.85 / $0.85 / $851.14
| Facility | | $0.85 | $0.85 | $851.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $851.14 / $851.14
| Professional | | $851.14 | $851.14 | $851.14 |