- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $761.86 / $1,000.18 / $1,139.74
| Professional | | $761.86 | $1,000.18 | $1,139.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $840.47 / $913.55 / $913.55
| Professional | | $840.47 | $913.55 | $913.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $606.51 / $606.51 / $1,369.09
| Facility | | $606.51 | $606.51 | $1,369.09 |
- 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 / $711.30 / $1,104.84
| Professional | | $465.20 | $711.30 | $1,104.84 |