- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.14 / $297.45 / $1,280.25
| Professional | | $97.14 | $297.45 | $1,280.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,101.02 / $1,149.09 / $1,555.00
| Facility | | $1,101.02 | $1,149.09 | $1,555.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $385.69 / $454.64 / $1,086.26
| Professional | | $385.69 | $454.64 | $1,086.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.90 / $355.87 / $1,086.26
| Professional | | $151.90 | $355.87 | $1,086.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $174.75 / $418.38 / $1,086.26
| Professional | | $174.75 | $418.38 | $1,086.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.26 / $492.71 / $1,253.73
| Professional | | $354.26 | $492.71 | $1,253.73 |