- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $977.24 / $1,202.26
| Professional | | $977.24 | $977.24 | $1,202.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $54.95 / $56.23 / $2,238.72
| Facility | | $54.95 | $56.23 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,235.94 / $3,235.94 / $4,168.69
| Professional | | $3,235.94 | $3,235.94 | $4,168.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $660.69 / $891.25 / $1,348.96
| Facility | | $660.69 | $891.25 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,202.26 / $1,445.44
| Professional | | $1,122.02 | $1,202.26 | $1,445.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $660.69 / $891.25 / $1,412.54
| Facility | | $660.69 | $891.25 | $1,412.54 |