- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,073.71 / $1,280.45 / $1,459.12
| Professional | | $1,073.71 | $1,280.45 | $1,459.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,072.43 / $1,165.68 / $1,165.68
| Professional | | $1,072.43 | $1,165.68 | $1,165.68 |
- 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 / $743.30 / $1,272.30
| Professional | | $531.80 | $743.30 | $1,272.30 |