- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $931.10 / $4,932.59 / $4,932.59
| Professional | | $931.10 | $4,932.59 | $4,932.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,557.42 / $1,557.42 / $1,557.42
| Facility | | $1,557.42 | $1,557.42 | $1,557.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $978.08 / $1,557.42 / $1,575.71
| Professional | | $978.08 | $1,557.42 | $1,575.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $839.26 / $1,060.50 / $2,044.10
| Facility | | $839.26 | $1,060.50 | $2,044.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $911.62 / $1,519.47 / $1,840.20
| Professional | | $911.62 | $1,519.47 | $1,840.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,399.53 / $1,583.98 / $1,747.84
| Professional | | $1,399.53 | $1,583.98 | $1,747.84 |