- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $732.65 / $1,080.72 / $1,080.72
| Professional | | $732.65 | $1,080.72 | $1,080.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,042.44 / $1,042.44 / $1,042.44
| Facility | | $1,042.44 | $1,042.44 | $1,042.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $886.07 / $1,042.44 / $2,090.63
| Professional | | $886.07 | $1,042.44 | $2,090.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $116.00 / $1,080.72 / $1,136.79
| Facility | | $116.00 | $1,080.72 | $1,136.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $903.00 / $903.00 / $903.00
| Professional | | $903.00 | $903.00 | $903.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $442.77 / $636.91 / $1,036.02
| Professional | | $442.77 | $636.91 | $1,036.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,554.45 / $7,892.17 / $7,892.17
| Facility | | $1,554.45 | $7,892.17 | $7,892.17 |