- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $576.20 / $912.76 / $1,056.63
| Professional | | $576.20 | $912.76 | $1,056.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,227.53 / $1,227.53 / $1,227.53
| Professional | | $1,227.53 | $1,227.53 | $1,227.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $614.72 / $867.06 / $1,049.67
| Facility | | $614.72 | $867.06 | $1,049.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $30.00
| Professional | | $30.00 | $30.00 | $30.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $644.63 / $862.81 / $1,147.15
| Professional | | $644.63 | $862.81 | $1,147.15 |