- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $748.56 / $913.13 / $1,011.00
| Professional | | $748.56 | $913.13 | $1,011.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $90.37 / $111.22 / $982.89
| Facility | | $90.37 | $111.22 | $982.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $90.37 / $114.50 / $1,058.50
| Professional | | $90.37 | $114.50 | $1,058.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,546.08 / $1,546.08 / $1,546.08
| Facility | | $1,546.08 | $1,546.08 | $1,546.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $115.61 / $115.61 / $6,465.60
| Professional | | $115.61 | $115.61 | $6,465.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $504.37 / $693.77 / $1,113.84
| Professional | | $504.37 | $693.77 | $1,113.84 |