- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $691.83 / $1,096.48
| Professional | | $691.83 | $691.83 | $1,096.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $1,995.26 / $1,995.26
| Facility | | $1,995.26 | $1,995.26 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $537.03 / $912.01 / $2,454.71
| Professional | | $537.03 | $912.01 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,621.81 / $3,235.94
| Professional | | $1,023.29 | $1,621.81 | $3,235.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $66.07 / $489.78 / $851.14
| Facility | | $66.07 | $489.78 | $851.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $1,258.93 / $2,454.71
| Professional | | $562.34 | $1,258.93 | $2,454.71 |