- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $685.30 / $685.30 / $1,171.40
| Professional | | $685.30 | $685.30 | $1,171.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,306.40 / $1,306.40 / $1,306.40
| Professional | | $1,306.40 | $1,306.40 | $1,306.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $359.59 / $359.59 / $1,128.88
| Facility | | $359.59 | $359.59 | $1,128.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $359.59 / $359.59 / $359.59
| Professional | | $359.59 | $359.59 | $359.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $422.90 / $576.86 / $1,011.64
| Professional | | $422.90 | $576.86 | $1,011.64 |