- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $679.58 / $1,187.26 / $1,200.59
| Professional | | $679.58 | $1,187.26 | $1,200.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,093.28 / $1,093.28 / $1,093.28
| Professional | | $1,093.28 | $1,093.28 | $1,093.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $642.26 / $642.26 / $642.26
| Facility | | $642.26 | $642.26 | $642.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $118.88 / $642.26 / $1,755.00
| Professional | | $118.88 | $642.26 | $1,755.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $504.16 / $756.24 / $1,197.38
| Professional | | $504.16 | $756.24 | $1,197.38 |