- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $934.73 / $1,114.73 / $1,270.28
| Professional | | $934.73 | $1,114.73 | $1,270.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.60 / $1,014.78 / $1,014.78
| Professional | | $933.60 | $1,014.78 | $1,014.78 |
- 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
- $471.88 / $656.45 / $1,028.61
| Professional | | $471.88 | $656.45 | $1,028.61 |