- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $149.88 / $1,555.26 / $2,727.94
| Professional | | $149.88 | $1,555.26 | $2,727.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $157.32 / $157.32 / $195.14
| Professional | | $157.32 | $157.32 | $195.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,034.56 / $1,034.56 / $1,034.56
| Facility | | $1,034.56 | $1,034.56 | $1,034.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $148.27 / $389.35 / $3,094.13
| Professional | | $148.27 | $389.35 | $3,094.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,003.13 / $1,725.38 / $3,226.06
| Professional | | $1,003.13 | $1,725.38 | $3,226.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,471.21 / $1,915.60 / $3,182.49
| Professional | | $1,471.21 | $1,915.60 | $3,182.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,337.50 / $1,337.50 / $1,890.65
| Professional | | $1,337.50 | $1,337.50 | $1,890.65 |