- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,012.05 / $1,012.05 / $1,265.06
| Professional | | $1,012.05 | $1,012.05 | $1,265.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $686.39 / $1,097.26 / $1,329.04
| Facility | | $686.39 | $1,097.26 | $1,329.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $732.00 / $6,244.00 / $6,244.00
| Professional | | $732.00 | $6,244.00 | $6,244.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $894.00 / $894.00 / $894.00
| Facility | | $894.00 | $894.00 | $894.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $732.00 / $821.00 / $965.80
| Professional | | $732.00 | $821.00 | $965.80 |