- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $781.17 / $1,152.71 / $1,570.36
| Professional | | $781.17 | $1,152.71 | $1,570.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $816.60 / $961.80 / $1,019.66
| Professional | | $816.60 | $961.80 | $1,019.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $124.05 / $1,223.23 / $1,223.23
| Professional | | $124.05 | $1,223.23 | $1,223.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $102.02 / $718.36 / $7,874.71
| Facility | | $102.02 | $718.36 | $7,874.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $492.41 / $737.83 / $1,455.93
| Professional | | $492.41 | $737.83 | $1,455.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $541.07 / $737.83 / $1,253.84
| Professional | | $541.07 | $737.83 | $1,253.84 |