- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $988.57 / $1,603.92 / $1,603.92
| Professional | | $988.57 | $1,603.92 | $1,603.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $975.26 / $975.26 / $975.26
| Facility | | $975.26 | $975.26 | $975.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $161.82 / $975.26 / $2,655.00
| Professional | | $161.82 | $975.26 | $2,655.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $626.80 / $1,603.92 / $1,804.41
| Facility | | $626.80 | $1,603.92 | $1,804.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,551.00 / $1,551.00 / $1,551.00
| Professional | | $1,551.00 | $1,551.00 | $1,551.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $658.16 / $923.96 / $1,493.57
| Professional | | $658.16 | $923.96 | $1,493.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,097.30 / $10,647.60 / $10,647.60
| Facility | | $2,097.30 | $10,647.60 | $10,647.60 |