- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $172.44 / $1,484.56 / $1,484.56
| Professional | | $172.44 | $1,484.56 | $1,484.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,162.79 / $2,804.91 / $3,162.90
| Facility | | $2,162.79 | $2,804.91 | $3,162.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $116.94 / $250.33 / $256.89
| Professional | | $116.94 | $250.33 | $256.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $695.05 / $773.70 / $1,203.88
| Professional | | $695.05 | $773.70 | $1,203.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $172.44 / $1,484.56 / $1,484.56
| Professional | | $172.44 | $1,484.56 | $1,484.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $490.59 / $581.44 / $1,079.86
| Professional | | $490.59 | $581.44 | $1,079.86 |