- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $981.61 / $5,288.96 / $5,288.96
| Professional | | $981.61 | $5,288.96 | $5,288.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,596.85 / $1,596.85 / $1,596.85
| Facility | | $1,596.85 | $1,596.85 | $1,596.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,019.79 / $1,596.85 / $1,673.01
| Professional | | $1,019.79 | $1,596.85 | $1,673.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $896.47 / $1,087.92 / $2,220.08
| Facility | | $896.47 | $1,087.92 | $2,220.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $966.94 / $1,596.85 / $1,958.69
| Professional | | $966.94 | $1,596.85 | $1,958.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,505.91 / $1,623.37 / $1,835.47
| Professional | | $1,505.91 | $1,623.37 | $1,835.47 |