- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $687.10 / $1,052.08 / $2,159.84
| Professional | | $687.10 | $1,052.08 | $2,159.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $500.00 / $1,963.13 / $3,271.25
| Facility | | $500.00 | $1,963.13 | $3,271.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $418.75 / $500.00 / $581.25
| Professional | | $418.75 | $500.00 | $581.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $577.04 / $577.04 / $781.69
| Professional | | $577.04 | $577.04 | $781.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $721.46 / $2,159.84 / $3,088.57
| Facility | | $721.46 | $2,159.84 | $3,088.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,463.01 / $1,463.01 / $1,463.01
| Professional | | $1,463.01 | $1,463.01 | $1,463.01 |