- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $1,000.00 / $1,202.26
| Professional | | $562.34 | $1,000.00 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,047.13 / $1,047.13
| Professional | | $1,047.13 | $1,047.13 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.03 / $1,230.27 / $2,137.96
| Professional | | $123.03 | $1,230.27 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $58.88 / $446.68 / $870.96
| Facility | | $58.88 | $446.68 | $870.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $446.68 / $616.60 / $977.24
| Professional | | $446.68 | $616.60 | $977.24 |