- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $630.96 / $1,096.48
| Professional | | $616.60 | $630.96 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,230.27 / $1,230.27
| Professional | | $1,230.27 | $1,230.27 | $1,230.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $758.58 / $758.58 / $1,071.52
| Facility | | $758.58 | $758.58 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $758.58 / $758.58
| Professional | | $758.58 | $758.58 | $758.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $39.81 / $346.74 / $831.76
| Facility | | $39.81 | $346.74 | $831.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.05 / $524.81 / $831.76
| Professional | | $389.05 | $524.81 | $831.76 |