- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $863.10 / $1,118.76 / $1,183.88
| Professional | | $863.10 | $1,118.76 | $1,183.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,210.29 / $1,423.87 / $1,423.87
| Professional | | $1,210.29 | $1,423.87 | $1,423.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $213.28 / $213.28 / $1,414.26
| Facility | | $213.28 | $213.28 | $1,414.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.28 / $1,202.11 / $1,414.26
| Professional | | $213.28 | $1,202.11 | $1,414.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,146.66 / $1,547.34 / $2,416.80
| Professional | | $1,146.66 | $1,547.34 | $2,416.80 |