- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.18 / $1,148.15 / $1,445.44
| Professional | | $162.18 | $1,148.15 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $1,412.54 / $1,548.82
| Professional | | $151.36 | $1,412.54 | $1,548.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $147.91 / $831.76 / $1,122.02
| Facility | | $147.91 | $831.76 | $1,122.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.91 / $977.24 / $4,265.80
| Professional | | $147.91 | $977.24 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.04 / $138.04 / $977.24
| Professional | | $138.04 | $138.04 | $977.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.01 / $1,071.52 / $1,288.25
| Professional | | $5.01 | $1,071.52 | $1,288.25 |