- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $809.36 / $1,332.72 / $1,411.11
| Professional | | $809.36 | $1,332.72 | $1,411.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,211.00 / $1,211.00 / $1,211.00
| Professional | | $1,211.00 | $1,211.00 | $1,211.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $396.70 / $396.70 / $396.70
| Facility | | $396.70 | $396.70 | $396.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $148.88 / $396.70 / $2,077.50
| Professional | | $148.88 | $396.70 | $2,077.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $531.80 / $788.10 / $1,172.01
| Professional | | $531.80 | $788.10 | $1,172.01 |