- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $774.57 / $4,170.55 / $4,170.55
| Professional | | $774.57 | $4,170.55 | $4,170.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,262.97 / $1,262.97 / $1,262.97
| Facility | | $1,262.97 | $1,262.97 | $1,262.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $792.24 / $1,262.97 / $1,314.26
| Professional | | $792.24 | $1,262.97 | $1,314.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $708.34 / $861.00 / $1,744.88
| Facility | | $708.34 | $861.00 | $1,744.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $763.78 / $1,262.97 / $1,548.82
| Professional | | $763.78 | $1,262.97 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,113.59 / $1,322.39 / $1,445.06
| Professional | | $1,113.59 | $1,322.39 | $1,445.06 |