- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,013.84 / $1,252.79 / $1,565.99
| Professional | | $1,013.84 | $1,252.79 | $1,565.99 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $513.60 / $1,149.44 / $1,253.83
| Facility | | $513.60 | $1,149.44 | $1,253.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,018.40 / $3,018.40 / $3,018.40
| Professional | | $3,018.40 | $3,018.40 | $3,018.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,035.00 / $1,035.00 / $1,035.00
| Facility | | $1,035.00 | $1,035.00 | $1,035.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $947.00 / $1,153.00 / $1,200.02
| Professional | | $947.00 | $1,153.00 | $1,200.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.19 / $968.93 / $985.13
| Professional | | $562.19 | $968.93 | $985.13 |