- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $977.24 / $1,174.90
| Professional | | $501.19 | $977.24 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,089.30 / $2,089.30
| Professional | | $2,089.30 | $2,089.30 | $2,089.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $263.03 / $263.03 / $263.03
| Facility | | $263.03 | $263.03 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $912.01 / $1,047.13
| Professional | | $741.31 | $912.01 | $1,047.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,445.44 / $1,445.44
| Facility | | $1,445.44 | $1,445.44 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $2,041.74 / $2,041.74
| Professional | | $630.96 | $2,041.74 | $2,041.74 |