- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $981.03 / $1,285.70 / $1,465.10
| Professional | | $981.03 | $1,285.70 | $1,465.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,075.31 / $1,168.81 / $1,168.81
| Professional | | $1,075.31 | $1,168.81 | $1,168.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $504.00 / $504.00 / $1,767.72
| Facility | | $504.00 | $504.00 | $1,767.72 |
- 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
- $747.50 / $1,206.80 / $1,757.85
| Professional | | $747.50 | $1,206.80 | $1,757.85 |