- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $659.35 / $659.35 / $1,018.90
| Professional | | $659.35 | $659.35 | $1,018.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,136.40 / $1,136.40 / $1,136.40
| Professional | | $1,136.40 | $1,136.40 | $1,136.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $840.94 / $840.94 / $1,127.58
| Facility | | $840.94 | $840.94 | $1,127.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $840.94 / $840.94 / $840.94
| Professional | | $840.94 | $840.94 | $840.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $422.15 / $498.91 / $711.59
| Professional | | $422.15 | $498.91 | $711.59 |