- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $752.81 / $1,138.03 / $1,138.03
| Professional | | $752.81 | $1,138.03 | $1,138.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,143.60 / $1,143.60 / $1,143.60
| Professional | | $1,143.60 | $1,143.60 | $1,143.60 |
- 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 / $337.20 / $396.70
| Professional | | $148.88 | $337.20 | $396.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.07 / $735.20 / $1,228.93
| Professional | | $177.07 | $735.20 | $1,228.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,406.58 / $1,558.46 / $1,983.49
| Professional | | $1,406.58 | $1,558.46 | $1,983.49 |