- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.00 / $1,438.40 / $1,438.40
| Professional | | $812.00 | $1,438.40 | $1,438.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,941.55 / $1,941.55 / $1,941.55
| Facility | | $1,941.55 | $1,941.55 | $1,941.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,546.23 / $1,546.23 / $1,546.23
| Professional | | $1,546.23 | $1,546.23 | $1,546.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,941.55 / $1,941.55 / $1,941.55
| Facility | | $1,941.55 | $1,941.55 | $1,941.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $754.00 / $754.00 / $1,546.23
| Professional | | $754.00 | $754.00 | $1,546.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $506.69 / $1,160.00 / $5,220.00
| Professional | | $506.69 | $1,160.00 | $5,220.00 |