- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $731.78 / $1,091.08 / $1,461.26
| Professional | | $731.78 | $1,091.08 | $1,461.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $192.60 / $1,436.52 / $1,436.52
| Facility | | $192.60 | $1,436.52 | $1,436.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,221.04 / $1,221.04 / $1,221.04
| Professional | | $1,221.04 | $1,221.04 | $1,221.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $192.60 / $1,436.52 / $1,436.52
| Facility | | $192.60 | $1,436.52 | $1,436.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $734.12 / $1,396.37 / $1,950.30
| Professional | | $734.12 | $1,396.37 | $1,950.30 |