- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.71 / $1,139.61 / $1,139.61
| Professional | | $831.71 | $1,139.61 | $1,139.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $940.94 / $1,032.51 / $1,032.51
| Professional | | $940.94 | $1,032.51 | $1,032.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $107.63 / $107.63 / $108.99
| Facility | | $107.63 | $107.63 | $108.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $91.49 / $107.63 / $144.13
| Professional | | $91.49 | $107.63 | $144.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $800.30 / $1,139.61 / $1,139.61
| Professional | | $800.30 | $1,139.61 | $1,139.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $63.31 / $94.97 / $808.54
| Professional | | $63.31 | $94.97 | $808.54 |