- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $590.24 / $1,054.56 / $1,105.92
| Professional | | $590.24 | $1,054.56 | $1,105.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.86 / $1,047.86 / $1,047.86
| Professional | | $1,047.86 | $1,047.86 | $1,047.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $606.51 / $606.51 / $606.51
| Facility | | $606.51 | $606.51 | $606.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.05 / $606.51 / $1,627.50
| Professional | | $112.05 | $606.51 | $1,627.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $465.20 / $697.80 / $1,104.84
| Professional | | $465.20 | $697.80 | $1,104.84 |