- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $943.38 / $1,153.16 / $1,196.07
| Professional | | $943.38 | $1,153.16 | $1,196.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $968.03 / $1,052.21 / $1,052.21
| Professional | | $968.03 | $1,052.21 | $1,052.21 |
- 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 / $642.73 / $1,084.58
| Professional | | $453.23 | $642.73 | $1,084.58 |