- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $804.55 / $1,408.25 / $1,424.07
| Professional | | $804.55 | $1,408.25 | $1,424.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,294.33 / $1,294.33 / $1,294.33
| Professional | | $1,294.33 | $1,294.33 | $1,294.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $504.00 / $504.00 / $504.00
| Facility | | $504.00 | $504.00 | $504.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.11 / $504.00 / $2,081.25
| Professional | | $141.11 | $504.00 | $2,081.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $598.00 / $897.00 / $1,992.23
| Professional | | $598.00 | $897.00 | $1,992.23 |