- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $794.33 / $794.33
| Professional | | $794.33 | $794.33 | $794.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $537.03 / $724.44 / $1,071.52
| Facility | | $537.03 | $724.44 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $891.25 / $1,047.13
| Professional | | $758.58 | $891.25 | $1,047.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $56.23 / $1,819.70 / $1,862.09
| Facility | | $56.23 | $1,819.70 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,309.57 / $6,309.57 / $6,309.57
| Professional | | $6,309.57 | $6,309.57 | $6,309.57 |