- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $963.63 / $1,646.10 / $2,057.63
| Professional | | $963.63 | $1,646.10 | $2,057.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,850.09 / $1,850.09 / $3,065.16
| Facility | | $1,850.09 | $1,850.09 | $3,065.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $249.23 / $1,572.58 / $4,560.93
| Professional | | $249.23 | $1,572.58 | $4,560.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $999.23 / $2,351.14 / $16,606.15
| Facility | | $999.23 | $2,351.14 | $16,606.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,295.95 / $2,155.09 / $3,162.34
| Professional | | $1,295.95 | $2,155.09 | $3,162.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,295.95 / $2,155.09 / $2,907.65
| Professional | | $1,295.95 | $2,155.09 | $2,907.65 |