- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.26 / $1,106.76 / $1,383.45
| Professional | | $645.26 | $1,106.76 | $1,383.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $396.70 / $396.70 / $396.70
| Facility | | $396.70 | $396.70 | $396.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $148.88 / $396.70 / $2,077.50
| Professional | | $148.88 | $396.70 | $2,077.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $126.40 / $808.94 / $9,451.79
| Facility | | $126.40 | $808.94 | $9,451.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $591.00 / $885.78 / $1,401.67
| Professional | | $591.00 | $885.78 | $1,401.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $652.75 / $885.26 / $1,401.67
| Professional | | $652.75 | $885.26 | $1,401.67 |