- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,070.61 / $1,377.20 / $1,408.25
| Professional | | $1,070.61 | $1,377.20 | $1,408.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,111.29 / $1,408.80 / $1,408.80
| Professional | | $1,111.29 | $1,408.80 | $1,408.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $504.00 / $504.00 / $504.00
| Facility | | $504.00 | $504.00 | $504.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $428.40 / $504.00 / $504.00
| Professional | | $428.40 | $504.00 | $504.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,226.32 / $1,226.32 / $1,226.32
| Professional | | $1,226.32 | $1,226.32 | $1,226.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $853.65 / $1,034.76 / $1,640.66
| Professional | | $853.65 | $1,034.76 | $1,640.66 |