- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,288.25 / $1,548.82
| Professional | | $812.83 | $1,288.25 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,202.26 / $1,202.26
| Professional | | $1,202.26 | $1,202.26 | $1,202.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $398.11 / $398.11 / $398.11
| Facility | | $398.11 | $398.11 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.91 / $398.11 / $2,089.30
| Professional | | $147.91 | $398.11 | $2,089.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $83.18 / $537.03 / $1,174.90
| Facility | | $83.18 | $537.03 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $537.03 / $794.33 / $1,174.90
| Professional | | $537.03 | $794.33 | $1,174.90 |