- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $932.33 / $6,826.77 / $6,826.77
| Professional | | $932.33 | $6,826.77 | $6,826.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,395.53 / $1,872.85 / $1,872.85
| Facility | | $1,395.53 | $1,872.85 | $1,872.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,340.43 / $1,872.85 / $1,872.85
| Professional | | $1,340.43 | $1,872.85 | $1,872.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $994.43 / $1,783.67 / $1,872.85
| Facility | | $994.43 | $1,783.67 | $1,872.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,405.66 / $1,436.81 / $1,952.30
| Professional | | $1,405.66 | $1,436.81 | $1,952.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $804.26 / $889.85 / $1,361.71
| Professional | | $804.26 | $889.85 | $1,361.71 |