- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $812.83 / $1,023.29
| Professional | | $812.83 | $812.83 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $151.36 / $1,000.00
| Professional | | $151.36 | $151.36 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $54.95 / $676.08 / $3,890.45
| Facility | | $54.95 | $676.08 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $891.25 / $3,630.78
| Professional | | $676.08 | $891.25 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $758.58 / $758.58
| Professional | | $758.58 | $758.58 | $758.58 |