- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $903.88 / $6,618.47 / $6,618.47
| Professional | | $903.88 | $6,618.47 | $6,618.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,212.63 / $1,806.45 / $1,806.45
| Facility | | $1,212.63 | $1,806.45 | $1,806.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,212.63 / $1,469.02 / $1,806.45
| Professional | | $1,212.63 | $1,469.02 | $1,806.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $959.18 / $1,720.43 / $1,806.45
| Facility | | $959.18 | $1,720.43 | $1,806.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,212.63 / $1,355.82 / $1,807.76
| Professional | | $1,212.63 | $1,355.82 | $1,807.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $775.75 / $858.30 / $1,313.43
| Professional | | $775.75 | $858.30 | $1,313.43 |