- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $836.54 / $6,125.35 / $6,125.35
| Professional | | $836.54 | $6,125.35 | $6,125.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,540.39 / $2,308.94 / $2,308.94
| Facility | | $1,540.39 | $2,308.94 | $2,308.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,540.39 / $2,308.94 / $2,308.94
| Professional | | $1,540.39 | $2,308.94 | $2,308.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,083.33 / $2,199.00 / $2,308.94
| Facility | | $1,083.33 | $2,199.00 | $2,308.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,540.39 / $1,732.97 / $2,310.62
| Professional | | $1,540.39 | $1,732.97 | $2,310.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $876.16 / $969.40 / $1,109.69
| Professional | | $876.16 | $969.40 | $1,109.69 |