- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $626.79 / $645.61 / $1,383.38
| Professional | | $626.79 | $645.61 | $1,383.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,403.43 / $1,403.43 / $1,685.57
| Professional | | $1,403.43 | $1,403.43 | $1,685.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $173.31 / $1,082.51 / $1,082.51
| Facility | | $173.31 | $1,082.51 | $1,082.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $161.82 / $1,082.51 / $2,655.00
| Professional | | $161.82 | $1,082.51 | $2,655.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $228.97 / $228.97 / $228.97
| Professional | | $228.97 | $228.97 | $228.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $772.80 / $963.59 / $1,605.99
| Professional | | $772.80 | $963.59 | $1,605.99 |