- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $887.49 / $1,060.14 / $1,091.79
| Professional | | $887.49 | $1,060.14 | $1,091.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,107.60 / $1,107.60 / $1,408.80
| Professional | | $1,107.60 | $1,107.60 | $1,408.80 |
- 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
- $311.75 / $311.75 / $311.75
| Professional | | $311.75 | $311.75 | $311.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $896.03 / $897.00 / $1,673.25
| Professional | | $896.03 | $897.00 | $1,673.25 |