- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $995.25 / $995.25 / $1,844.60
| Professional | | $995.25 | $995.25 | $1,844.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,057.19 / $2,057.19 / $2,057.19
| Professional | | $2,057.19 | $2,057.19 | $2,057.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $396.70 / $396.70 / $1,734.73
| Facility | | $396.70 | $396.70 | $1,734.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $396.70 / $396.70 / $396.70
| Professional | | $396.70 | $396.70 | $396.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $649.98 / $768.16 / $1,095.33
| Professional | | $649.98 | $768.16 | $1,095.33 |