- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $754.68 / $5,526.01 / $5,526.01
| Professional | | $754.68 | $5,526.01 | $5,526.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $897.58 / $1,710.54 / $1,710.54
| Facility | | $897.58 | $1,710.54 | $1,710.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $897.58 / $1,710.54 / $1,710.54
| Professional | | $897.58 | $1,710.54 | $1,710.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $800.86 / $1,629.09 / $1,710.54
| Facility | | $800.86 | $1,629.09 | $1,710.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,283.83 / $1,312.30 / $1,783.11
| Professional | | $1,283.83 | $1,312.30 | $1,783.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $647.70 / $716.63 / $1,096.64
| Professional | | $647.70 | $716.63 | $1,096.64 |