- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $527.20 / $527.20 / $1,259.09
| Professional | | $527.20 | $527.20 | $1,259.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.70 / $1,023.70 / $1,023.70
| Professional | | $1,023.70 | $1,023.70 | $1,023.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $845.38 / $845.38 / $845.38
| Facility | | $845.38 | $845.38 | $845.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $718.57 / $718.57 / $845.38
| Professional | | $718.57 | $718.57 | $845.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $65.62 / $113.69 / $1,761.55
| Professional | | $65.62 | $113.69 | $1,761.55 |