- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $933.25 / $1,202.26
| Professional | | $645.65 | $933.25 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,096.48 / $1,096.48
| Professional | | $1,096.48 | $1,096.48 | $1,096.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $645.65 / $645.65 / $1,513.56
| Facility | | $645.65 | $645.65 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.23 / $645.65 / $1,737.80
| Professional | | $120.23 | $645.65 | $1,737.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $74.13 / $562.34 / $1,174.90
| Facility | | $74.13 | $562.34 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $758.58 / $1,202.26
| Professional | | $501.19 | $758.58 | $1,202.26 |