- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $757.76 / $1,045.11 / $1,045.11
| Professional | | $757.76 | $1,045.11 | $1,045.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $124.05 / $1,223.23 / $2,160.94
| Professional | | $124.05 | $1,223.23 | $2,160.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $113.00 / $1,045.11 / $1,149.63
| Facility | | $113.00 | $1,045.11 | $1,149.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.00 / $851.00 / $851.00
| Professional | | $851.00 | $851.00 | $851.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $492.41 / $658.70 / $1,071.51
| Professional | | $492.41 | $658.70 | $1,071.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,607.47 / $8,161.83 / $8,161.83
| Facility | | $1,607.47 | $8,161.83 | $8,161.83 |