- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $983.60 / $983.60 / $1,972.10
| Professional | | $983.60 | $983.60 | $1,972.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,909.90 / $1,909.90 / $1,909.90
| Professional | | $1,909.90 | $1,909.90 | $1,909.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,762.01 / $1,762.01 / $1,762.01
| Facility | | $1,762.01 | $1,762.01 | $1,762.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $139.37 / $896.13 / $1,570.80
| Facility | | $139.37 | $896.13 | $1,570.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $993.47 / $1,096.45 / $1,668.82
| Professional | | $993.47 | $1,096.45 | $1,668.82 |