- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $315.44 / $396.31 / $396.31
| Professional | | $315.44 | $396.31 | $396.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.00 / $2,347.21 / $2,681.26
| Professional | | $150.00 | $2,347.21 | $2,681.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $509.88 / $851.83 / $1,243.43
| Facility | | $509.88 | $851.83 | $1,243.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $626.88 / $1,347.59 / $3,879.51
| Professional | | $626.88 | $1,347.59 | $3,879.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $615.41 / $911.22 / $1,382.00
| Facility | | $615.41 | $911.22 | $1,382.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $615.41 / $969.96 / $1,528.18
| Professional | | $615.41 | $969.96 | $1,528.18 |