- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $489.78 / $758.58 / $1,513.56
| Professional | | $489.78 | $758.58 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $1,698.24 / $1,698.24
| Professional | | $1,698.24 | $1,698.24 | $1,698.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $851.14 / $851.14 / $1,513.56
| Facility | | $851.14 | $851.14 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $851.14 / $851.14
| Professional | | $851.14 | $851.14 | $851.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $57.54 / $489.78 / $1,202.26
| Facility | | $57.54 | $489.78 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $758.58 / $1,202.26
| Professional | | $549.54 | $758.58 | $1,202.26 |