- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,225.52 / $1,225.52 / $1,531.91
| Professional | | $1,225.52 | $1,225.52 | $1,531.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,039.30 / $6,039.30 / $6,039.30
| Facility | | $6,039.30 | $6,039.30 | $6,039.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $878.00 / $4,012.68 / $4,012.68
| Professional | | $878.00 | $4,012.68 | $4,012.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $660.94 / $856.58 / $954.31
| Facility | | $660.94 | $856.58 | $954.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $679.13 / $1,088.84 / $1,148.05
| Professional | | $679.13 | $1,088.84 | $1,148.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.00 / $815.90 / $1,249.30
| Professional | | $3.00 | $815.90 | $1,249.30 |