- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,479.11 / $1,479.11
| Professional | | $831.76 | $1,479.11 | $1,479.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $870.96 / $1,096.48
| Professional | | $870.96 | $870.96 | $1,096.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $954.99 / $2,398.83 / $2,398.83
| Facility | | $954.99 | $2,398.83 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,162.28 / $3,162.28
| Professional | | $3,162.28 | $3,162.28 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $338.84 / $338.84 / $851.14
| Facility | | $338.84 | $338.84 | $851.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $851.14 / $851.14
| Professional | | $758.58 | $851.14 | $851.14 |