- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $755.48 / $1,202.84 / $1,202.84
| Professional | | $755.48 | $1,202.84 | $1,202.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,032.30 / $1,032.30 / $1,032.30
| Professional | | $1,032.30 | $1,032.30 | $1,032.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $860.04 / $860.04 / $860.04
| Facility | | $860.04 | $860.04 | $860.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $126.91 / $860.04 / $2,081.25
| Professional | | $126.91 | $860.04 | $2,081.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $453.23 / $671.83 / $999.87
| Professional | | $453.23 | $671.83 | $999.87 |