- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,139.09 / $1,525.58 / $1,525.58
| Professional | | $1,139.09 | $1,525.58 | $1,525.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $213.28 / $1,414.26 / $1,414.26
| Facility | | $213.28 | $1,414.26 | $1,414.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.28 / $1,414.26 / $1,456.69
| Professional | | $213.28 | $1,414.26 | $1,456.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $213.28 / $1,414.26 / $1,414.26
| Facility | | $213.28 | $1,414.26 | $1,414.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.28 / $1,414.26 / $1,456.69
| Professional | | $213.28 | $1,414.26 | $1,456.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $901.16 / $1,978.54 / $2,252.90
| Professional | | $901.16 | $1,978.54 | $2,252.90 |