- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $925.22 / $925.22 / $5,060.72
| Professional | | $925.22 | $925.22 | $5,060.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,583.71 / $1,583.71 / $1,583.71
| Facility | | $1,583.71 | $1,583.71 | $1,583.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,031.33 / $1,583.71 / $1,629.60
| Professional | | $1,031.33 | $1,583.71 | $1,629.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $778.69 / $1,626.30 / $1,717.87
| Facility | | $778.69 | $1,626.30 | $1,717.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $955.94 / $1,434.06 / $2,068.50
| Professional | | $955.94 | $1,434.06 | $2,068.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,315.53 / $1,623.42 / $2,756.50
| Professional | | $1,315.53 | $1,623.42 | $2,756.50 |