- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $954.99 / $1,445.44
| Professional | | $676.08 | $954.99 | $1,445.44 |
- 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
- $512.86 / $512.86 / $512.86
| Facility | | $512.86 | $512.86 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $512.86 / $1,819.70
| Professional | | $125.89 | $512.86 | $1,819.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $72.44 / $467.74 / $1,023.29
| Facility | | $72.44 | $467.74 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.74 / $691.83 / $1,023.29
| Professional | | $467.74 | $691.83 | $1,023.29 |