- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $537.03 / $537.03 / $537.03
| Professional | | $537.03 | $537.03 | $537.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $426.58 / $562.34 / $1,096.48
| Facility | | $426.58 | $562.34 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $380.19 / $562.34 / $977.24
| Professional | | $380.19 | $562.34 | $977.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,623.41 / $5,623.41 / $5,623.41
| Facility | | $5,623.41 | $5,623.41 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $3,162.28 / $3,162.28
| Professional | | $2,754.23 | $3,162.28 | $3,162.28 |