- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $1,071.52 / $1,288.25
| Professional | | $630.96 | $1,071.52 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,023.29 / $1,023.29
| Professional | | $1,023.29 | $1,023.29 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.03 / $1,230.27 / $2,137.96
| Professional | | $123.03 | $1,230.27 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $69.18 / $446.68 / $977.24
| Facility | | $69.18 | $446.68 | $977.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $446.68 / $660.69 / $977.24
| Professional | | $446.68 | $660.69 | $977.24 |