- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $933.25 / $933.25 / $1,479.11
| Facility | | $933.25 | $933.25 | $1,479.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $933.25 / $8,912.51
| Professional | | $933.25 | $933.25 | $8,912.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,079.46 / $7,079.46 / $7,079.46
| Facility | | $7,079.46 | $7,079.46 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $660.69 / $1,230.27
| Professional | | $660.69 | $660.69 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $1,000.00 / $1,819.70
| Professional | | $602.56 | $1,000.00 | $1,819.70 |