- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $997.24 / $1,354.94 / $1,395.39
| Professional | | $997.24 | $1,354.94 | $1,395.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,415.61 / $1,415.61 / $1,700.29
| Professional | | $1,415.61 | $1,415.61 | $1,700.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $171.39 / $1,071.00 / $1,071.00
| Facility | | $171.39 | $1,071.00 | $1,071.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $163.22 / $1,071.00 / $2,677.50
| Professional | | $163.22 | $1,071.00 | $2,677.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $230.95 / $230.95 / $230.95
| Professional | | $230.95 | $230.95 | $230.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $663.91 / $972.04 / $1,420.42
| Professional | | $663.91 | $972.04 | $1,420.42 |