- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $1,158.53 / $1,781.16
| Professional | | $100.00 | $1,158.53 | $1,781.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $637.52 / $637.52 / $1,361.59
| Facility | | $637.52 | $637.52 | $1,361.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $637.52 / $637.52 / $637.52
| Professional | | $637.52 | $637.52 | $637.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $681.12 / $953.57 / $1,777.24
| Professional | | $681.12 | $953.57 | $1,777.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,843.96 / $4,843.96 / $17,524.30
| Facility | | $4,843.96 | $4,843.96 | $17,524.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,191.10 / $4,388.18 / $4,388.18
| Professional | | $4,191.10 | $4,388.18 | $4,388.18 |