- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.02 / $859.38 / $1,074.23
| Professional | | $501.02 | $859.38 | $1,074.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $115.61 / $1,140.20 / $2,371.88
| Professional | | $115.61 | $1,140.20 | $2,371.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $628.14 / $7,340.19
| Facility | | $100.00 | $628.14 | $7,340.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $458.92 / $687.77 / $1,088.40
| Professional | | $458.92 | $687.77 | $1,088.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $506.86 / $641.91 / $990.24
| Professional | | $506.86 | $641.91 | $990.24 |