- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $701.33 / $1,307.58 / $1,804.41
| Professional | | $701.33 | $1,307.58 | $1,804.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $171.73 / $206.07 / $206.07
| Professional | | $171.73 | $206.07 | $206.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $173.31 / $1,082.51 / $1,893.73
| Facility | | $173.31 | $1,082.51 | $1,893.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.91 / $1,082.51 / $2,655.00
| Professional | | $169.91 | $1,082.51 | $2,655.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $200.00 / $286.77
| Professional | | $100.00 | $200.00 | $286.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $157.38 / $257.60 / $1,573.76
| Professional | | $157.38 | $257.60 | $1,573.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $803.00 / $1,001.17 / $1,802.60
| Professional | | $803.00 | $1,001.17 | $1,802.60 |