- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $993.59 / $1,060.57 / $1,060.57
| Professional | | $993.59 | $1,060.57 | $1,060.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $429.78 / $507.03 / $709.18
| Facility | | $429.78 | $507.03 | $709.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.37 / $60.69 / $79.23
| Professional | | $1.37 | $60.69 | $79.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $595.00 / $1,020.00 / $1,020.00
| Facility | | $595.00 | $1,020.00 | $1,020.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,060.57 / $1,145.42 / $2,216.59
| Facility | | $1,060.57 | $1,145.42 | $2,216.59 |