- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $921.86 / $5,154.42 / $5,154.42
| Professional | | $921.86 | $5,154.42 | $5,154.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,162.34 / $1,563.16 / $2,368.79
| Facility | | $1,162.34 | $1,563.16 | $2,368.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $167.73 / $1,151.24 / $1,162.34
| Professional | | $167.73 | $1,151.24 | $1,162.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $478.92 / $1,362.75 / $2,368.79
| Facility | | $478.92 | $1,362.75 | $2,368.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $721.46 / $721.46 / $1,162.34
| Professional | | $721.46 | $721.46 | $1,162.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $188.59 / $336.68 / $801.62
| Professional | | $188.59 | $336.68 | $801.62 |