- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $714.06 / $1,276.38 / $1,323.72
| Professional | | $714.06 | $1,276.38 | $1,323.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.74 / $1,148.74 / $1,148.74
| Professional | | $1,148.74 | $1,148.74 | $1,148.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $799.37 / $799.37 / $799.37
| Facility | | $799.37 | $799.37 | $799.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $133.31 / $799.37 / $1,965.00
| Professional | | $133.31 | $799.37 | $1,965.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $555.84 / $965.93 / $2,174.30
| Professional | | $555.84 | $965.93 | $2,174.30 |