- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.56 / $1,160.17 / $1,445.22
| Professional | | $758.56 | $1,160.17 | $1,445.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,240.40 / $1,240.40 / $1,240.40
| Professional | | $1,240.40 | $1,240.40 | $1,240.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $511.03 / $511.03 / $511.03
| Facility | | $511.03 | $511.03 | $511.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $511.03 / $1,807.50
| Professional | | $125.89 | $511.03 | $1,807.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $462.88 / $686.08 / $1,021.02
| Professional | | $462.88 | $686.08 | $1,021.02 |