- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $800.40 / $909.83 / $1,000.50
| Professional | | $800.40 | $909.83 | $1,000.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $98.32 / $105.09 / $1,170.58
| Facility | | $98.32 | $105.09 | $1,170.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $98.32 / $113.17 / $1,260.63
| Professional | | $98.32 | $113.17 | $1,260.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $642.26 / $642.26 / $1,739.40
| Facility | | $642.26 | $642.26 | $1,739.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $118.88 / $642.26 / $1,061.01
| Professional | | $118.88 | $642.26 | $1,061.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,011.23 / $1,011.23 / $1,011.23
| Professional | | $1,011.23 | $1,011.23 | $1,011.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $658.88 / $897.58 / $1,342.27
| Professional | | $658.88 | $897.58 | $1,342.27 |