- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $827.08 / $1,083.94 / $1,235.19
| Professional | | $827.08 | $1,083.94 | $1,235.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $905.92 / $984.70 / $984.70
| Professional | | $905.92 | $984.70 | $984.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $642.26 / $642.26 / $1,490.35
| Facility | | $642.26 | $642.26 | $1,490.35 |
- 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
- $513.41 / $789.84 / $1,225.50
| Professional | | $513.41 | $789.84 | $1,225.50 |