- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $637.90 / $637.90 / $1,090.50
| Professional | | $637.90 | $637.90 | $1,090.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,216.20 / $1,216.20 / $1,216.20
| Professional | | $1,216.20 | $1,216.20 | $1,216.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $344.45 / $344.45 / $1,165.91
| Facility | | $344.45 | $344.45 | $1,165.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $344.45 / $344.45 / $344.45
| Professional | | $344.45 | $344.45 | $344.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $436.94 / $516.39 / $736.48
| Professional | | $436.94 | $516.39 | $736.48 |