- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $1,023.29 / $1,778.28
| Professional | | $776.25 | $1,023.29 | $1,778.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $512.86 / $512.86 / $512.86
| Facility | | $512.86 | $512.86 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $436.52 / $512.86 / $524.81
| Professional | | $436.52 | $512.86 | $524.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $91.20 / $676.08 / $1,023.29
| Facility | | $91.20 | $676.08 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $776.25 / $1,288.25
| Professional | | $512.86 | $776.25 | $1,288.25 |