- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $786.05 / $994.85 / $5,266.50
| Professional | | $786.05 | $994.85 | $5,266.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,588.97 / $1,588.97 / $1,588.97
| Facility | | $1,588.97 | $1,588.97 | $1,588.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $940.23 / $1,588.97 / $2,750.26
| Professional | | $940.23 | $1,588.97 | $2,750.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $977.03 / $1,263.71 / $1,775.43
| Facility | | $977.03 | $1,263.71 | $1,775.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,005.62 / $1,630.00 / $2,716.17
| Professional | | $1,005.62 | $1,630.00 | $2,716.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,374.28 / $1,637.44 / $2,110.52
| Professional | | $1,374.28 | $1,637.44 | $2,110.52 |