- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $963.48 / $1,023.68 / $1,133.48
| Professional | | $963.48 | $1,023.68 | $1,133.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $101.32 / $124.70 / $1,101.96
| Facility | | $101.32 | $124.70 | $1,101.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.32 / $128.37 / $1,186.73
| Professional | | $101.32 | $128.37 | $1,186.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $511.03 / $511.03 / $1,733.24
| Facility | | $511.03 | $511.03 | $1,733.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $511.03 / $7,248.27
| Professional | | $125.89 | $511.03 | $7,248.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $565.41 / $746.38 / $1,248.83
| Professional | | $565.41 | $746.38 | $1,248.83 |