- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $949.38 / $1,079.93 / $1,186.73
| Professional | | $949.38 | $1,079.93 | $1,186.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $116.70 / $202.64 / $1,388.47
| Facility | | $116.70 | $202.64 | $1,388.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.68 / $204.71 / $280.58
| Professional | | $125.68 | $204.71 | $280.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $504.00 / $504.00 / $2,064.88
| Facility | | $504.00 | $504.00 | $2,064.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.11 / $504.00 / $1,259.36
| Professional | | $141.11 | $504.00 | $1,259.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $916.26 / $1,194.70 / $2,231.00
| Professional | | $916.26 | $1,194.70 | $2,231.00 |