- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $710.47 / $710.47 / $710.47
| Professional | | $710.47 | $710.47 | $710.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $192.60 / $1,436.52 / $1,436.52
| Facility | | $192.60 | $1,436.52 | $1,436.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $183.43 / $1,221.04 / $3,759.38
| Professional | | $183.43 | $1,221.04 | $3,759.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $884.26 / $1,559.34 / $1,901.64
| Professional | | $884.26 | $1,559.34 | $1,901.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $710.47 / $1,092.43 / $1,578.82
| Professional | | $710.47 | $1,092.43 | $1,578.82 |