- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.60 / $5,047.03 / $5,047.03
| Professional | | $1,023.60 | $5,047.03 | $5,047.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,622.62 / $1,622.62 / $1,622.62
| Facility | | $1,622.62 | $1,622.62 | $1,622.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $987.83 / $1,622.62 / $1,724.47
| Professional | | $987.83 | $1,622.62 | $1,724.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $800.15 / $1,673.75 / $1,808.32
| Facility | | $800.15 | $1,673.75 | $1,808.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $969.53 / $1,454.44 / $2,097.90
| Professional | | $969.53 | $1,454.44 | $2,097.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,355.00 / $1,673.75 / $2,821.25
| Professional | | $1,355.00 | $1,673.75 | $2,821.25 |