- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $817.68 / $1,402.38 / $1,752.98
| Professional | | $817.68 | $1,402.38 | $1,752.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,639.62 / $1,639.62 / $2,583.51
| Facility | | $1,639.62 | $1,639.62 | $2,583.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $188.66 / $1,639.62 / $2,962.50
| Professional | | $188.66 | $1,639.62 | $2,962.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $266.93 / $1,654.90 / $11,977.62
| Facility | | $266.93 | $1,654.90 | $11,977.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $767.34 / $1,193.63 / $1,776.22
| Professional | | $767.34 | $1,193.63 | $1,776.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $767.34 / $1,123.40 / $1,773.40
| Professional | | $767.34 | $1,123.40 | $1,773.40 |