- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $921.65 / $6,748.59 / $6,748.59
| Professional | | $921.65 | $6,748.59 | $6,748.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,304.10 / $2,526.02 / $2,526.02
| Facility | | $1,304.10 | $2,526.02 | $2,526.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,304.10 / $2,054.17 / $2,526.02
| Professional | | $1,304.10 | $2,054.17 | $2,526.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,116.22 / $2,405.73 / $2,526.02
| Facility | | $1,116.22 | $2,405.73 | $2,526.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,304.10 / $1,895.89 / $2,527.85
| Professional | | $1,304.10 | $1,895.89 | $2,527.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $902.75 / $998.83 / $1,528.47
| Professional | | $902.75 | $998.83 | $1,528.47 |