- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $771.39 / $771.39 / $771.39
| Professional | | $771.39 | $771.39 | $771.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $213.28 / $1,414.26 / $1,414.26
| Facility | | $213.28 | $1,414.26 | $1,414.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $199.14 / $1,414.26 / $3,266.25
| Professional | | $199.14 | $1,414.26 | $3,266.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $956.43 / $1,686.61 / $2,673.90
| Professional | | $956.43 | $1,686.61 | $2,673.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,194.83 / $1,194.83 / $1,874.92
| Professional | | $1,194.83 | $1,194.83 | $1,874.92 |