- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $544.23 / $3,985.02 / $3,985.02
| Professional | | $544.23 | $3,985.02 | $3,985.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $732.96 / $1,087.67 / $1,087.67
| Facility | | $732.96 | $1,087.67 | $1,087.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $732.96 / $1,087.67 / $1,087.67
| Professional | | $732.96 | $1,087.67 | $1,087.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $577.52 / $1,035.88 / $1,087.67
| Facility | | $577.52 | $1,035.88 | $1,087.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $816.35 / $834.44 / $1,191.26
| Professional | | $816.35 | $834.44 | $1,191.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.08 / $516.79 / $635.00
| Professional | | $467.08 | $516.79 | $635.00 |