- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,096.48 / $1,659.59
| Professional | | $870.96 | $1,096.48 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $151.36 / $1,348.96
| Professional | | $151.36 | $151.36 | $1,348.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $524.81 / $851.14 / $1,348.96
| Facility | | $524.81 | $851.14 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $1,122.02 / $2,951.21
| Professional | | $758.58 | $1,122.02 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $954.99 / $954.99
| Professional | | $954.99 | $954.99 | $954.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $758.58 / $1,122.02
| Professional | | $758.58 | $758.58 | $1,122.02 |