- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $573.46 / $573.46 / $573.46
| Professional | | $573.46 | $573.46 | $573.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $642.27 / $1,123.86 / $2,372.23
| Professional | | $642.27 | $1,123.86 | $2,372.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $602.13 / $676.40 / $761.50
| Facility | | $602.13 | $676.40 | $761.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $167.55 / $705.89 / $2,824.72
| Professional | | $167.55 | $705.89 | $2,824.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $167.55 / $553.10 / $783.26
| Professional | | $167.55 | $553.10 | $783.26 |