- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $489.78 / $794.33 / $1,096.48
| Professional | | $489.78 | $794.33 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,348.96 / $1,348.96
| Professional | | $1,348.96 | $1,348.96 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $758.58 / $758.58
| Professional | | $758.58 | $758.58 | $758.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $79.43 / $100.00 / $3,388.44
| Facility | | $79.43 | $100.00 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.26 / $158.49 / $2,041.74
| Professional | | $60.26 | $158.49 | $2,041.74 |