- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $771.38 / $1,216.50 / $1,637.03
| Professional | | $771.38 | $1,216.50 | $1,637.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,660.75 / $1,977.93 / $3,086.52
| Professional | | $1,660.75 | $1,977.93 | $3,086.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $213.28 / $1,414.26 / $1,414.26
| Facility | | $213.28 | $1,414.26 | $1,414.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $199.14 / $1,414.26 / $3,266.25
| Professional | | $199.14 | $1,414.26 | $3,266.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $345.55 / $345.55 / $345.55
| Professional | | $345.55 | $345.55 | $345.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,033.02 / $1,194.83 / $1,991.40
| Professional | | $1,033.02 | $1,194.83 | $1,991.40 |