- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $310.25 / $1,415.02 / $5,979.64
| Professional | | $310.25 | $1,415.02 | $5,979.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $433.79 / $433.79 / $433.79
| Facility | | $433.79 | $433.79 | $433.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $323.91 / $433.79 / $1,763.53
| Professional | | $323.91 | $433.79 | $1,763.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $433.79 / $1,879.80 / $2,072.69
| Facility | | $433.79 | $1,879.80 | $2,072.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $291.62 / $1,087.36 / $2,195.14
| Professional | | $291.62 | $1,087.36 | $2,195.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,476.74 / $1,853.79 / $3,229.16
| Professional | | $1,476.74 | $1,853.79 | $3,229.16 |