- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $990.48 / $4,555.16 / $4,555.16
| Professional | | $990.48 | $4,555.16 | $4,555.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,383.38 / $1,383.38 / $1,383.38
| Facility | | $1,383.38 | $1,383.38 | $1,383.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,031.43 / $1,383.38 / $1,383.38
| Professional | | $1,031.43 | $1,383.38 | $1,383.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,383.38 / $1,683.50 / $1,727.36
| Facility | | $1,383.38 | $1,683.50 | $1,727.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $847.89 / $1,201.20 / $1,834.70
| Professional | | $847.89 | $1,201.20 | $1,834.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,320.90 / $1,542.00 / $2,424.41
| Professional | | $1,320.90 | $1,542.00 | $2,424.41 |