- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $1,047.13 / $1,380.38
| Professional | | $724.44 | $1,047.13 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $851.14 / $1,096.48
| Professional | | $851.14 | $851.14 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.83 / $1,230.27 / $1,230.27
| Professional | | $131.83 | $1,230.27 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,089.30 / $2,089.30
| Professional | | $2,089.30 | $2,089.30 | $2,089.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $741.31 / $1,122.02
| Facility | | $100.00 | $741.31 | $1,122.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $489.78 / $707.95 / $891.25
| Professional | | $489.78 | $707.95 | $891.25 |