- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.16 / $197.70 / $1,397.51
| Professional | | $158.16 | $197.70 | $1,397.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $126.64 / $241.40 / $1,037.30
| Facility | | $126.64 | $241.40 | $1,037.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,022.00 / $4,284.00 / $4,284.00
| Professional | | $1,022.00 | $4,284.00 | $4,284.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,022.00 / $1,022.00 / $1,022.00
| Facility | | $1,022.00 | $1,022.00 | $1,022.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.41 / $984.79 / $1,022.00
| Professional | | $138.41 | $984.79 | $1,022.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.00 / $128.90 / $1,168.80
| Professional | | $5.00 | $128.90 | $1,168.80 |