- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $721.17 / $5,280.61 / $5,280.61
| Professional | | $721.17 | $5,280.61 | $5,280.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $857.71 / $1,441.29 / $1,441.29
| Facility | | $857.71 | $1,441.29 | $1,441.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $857.71 / $1,172.07 / $1,441.29
| Professional | | $857.71 | $1,172.07 | $1,441.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $765.30 / $1,372.66 / $1,441.29
| Facility | | $765.30 | $1,372.66 | $1,441.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $857.71 / $1,081.76 / $1,578.56
| Professional | | $857.71 | $1,081.76 | $1,578.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $618.94 / $684.80 / $809.54
| Professional | | $618.94 | $684.80 | $809.54 |