- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $512.86 / $1,071.52
| Professional | | $512.86 | $512.86 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,174.90 / $1,174.90
| Professional | | $1,174.90 | $1,174.90 | $1,174.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $741.31 / $741.31 / $1,047.13
| Facility | | $741.31 | $741.31 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $741.31 / $741.31
| Professional | | $741.31 | $741.31 | $741.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $38.90 / $331.13 / $812.83
| Facility | | $38.90 | $331.13 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $512.86 / $812.83
| Professional | | $371.54 | $512.86 | $812.83 |