- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $519.84 / $808.50 / $1,010.63
| Professional | | $519.84 | $808.50 | $1,010.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,042.44 / $1,042.44 / $1,042.44
| Facility | | $1,042.44 | $1,042.44 | $1,042.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $119.94 / $886.07 / $2,090.63
| Professional | | $119.94 | $886.07 | $2,090.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $101.82 / $651.66 / $7,614.56
| Facility | | $101.82 | $651.66 | $7,614.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $476.10 / $713.49 / $1,129.14
| Professional | | $476.10 | $713.49 | $1,129.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $525.85 / $713.49 / $1,027.30
| Professional | | $525.85 | $713.49 | $1,027.30 |