- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $145.58 / $600.71 / $1,454.25
| Professional | | $145.58 | $600.71 | $1,454.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.94 / $2,344.94 / $2,533.35
| Facility | | $2,344.94 | $2,344.94 | $2,533.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $152.72 / $469.63 / $1,915.32
| Professional | | $152.72 | $469.63 | $1,915.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $197.79 / $838.39 / $1,915.32
| Professional | | $197.79 | $838.39 | $1,915.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $193.84 / $782.18 / $2,350.85
| Professional | | $193.84 | $782.18 | $2,350.85 |