- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $859.35 / $1,074.18 / $1,632.21
| Professional | | $859.35 | $1,074.18 | $1,632.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $682.26 / $1,251.96 / $1,412.26
| Facility | | $682.26 | $1,251.96 | $1,412.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,040.00 / $2,955.00 / $2,955.00
| Professional | | $1,040.00 | $2,955.00 | $2,955.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $948.00 / $948.00 / $948.00
| Facility | | $948.00 | $948.00 | $948.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $765.41 / $948.00 / $1,184.44
| Professional | | $765.41 | $948.00 | $1,184.44 |