- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,071.52 / $1,202.26
| Professional | | $812.83 | $1,071.52 | $1,202.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $158.49 / $158.49 / $158.49
| Facility | | $158.49 | $158.49 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.49 / $117.49 / $117.49
| Professional | | $117.49 | $117.49 | $117.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.03 / $1,230.27 / $1,230.27
| Professional | | $123.03 | $1,230.27 | $1,230.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $61.66 / $446.68 / $954.99
| Facility | | $61.66 | $446.68 | $954.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $489.78 / $537.03 / $1,000.00
| Professional | | $489.78 | $537.03 | $1,000.00 |