- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $941.32 / $941.32 / $1,086.14
| Professional | | $941.32 | $941.32 | $1,086.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,560.63 / $1,560.63 / $1,560.63
| Professional | | $1,560.63 | $1,560.63 | $1,560.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,037.25 / $1,037.25 / $1,037.25
| Facility | | $1,037.25 | $1,037.25 | $1,037.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $757.19 / $1,037.25 / $1,105.76
| Professional | | $757.19 | $1,037.25 | $1,105.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,037.25 / $1,037.25 / $1,037.25
| Facility | | $1,037.25 | $1,037.25 | $1,037.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $757.19 / $1,037.25 / $1,105.76
| Professional | | $757.19 | $1,037.25 | $1,105.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $641.57 / $1,230.96 / $2,227.77
| Professional | | $641.57 | $1,230.96 | $2,227.77 |