- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $618.59 / $2,145.54 / $2,145.54
| Professional | | $618.59 | $2,145.54 | $2,145.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $530.41 / $1,041.08 / $1,041.08
| Facility | | $530.41 | $1,041.08 | $1,041.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $530.41 / $1,041.08 / $1,041.08
| Professional | | $530.41 | $1,041.08 | $1,041.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $414.59 / $991.51 / $1,041.08
| Facility | | $414.59 | $991.51 | $1,041.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $745.12 / $784.51 / $1,041.83
| Professional | | $745.12 | $784.51 | $1,041.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $335.30 / $370.99 / $571.67
| Professional | | $335.30 | $370.99 | $571.67 |